In thyroid eye disease, the surgical order to be followed is conventionally orbital decompression followed by strabismus surgery followed by lid surgery. We don't have set up for decompression surgery but can do lid surgery. If the patient is not sure of decompression surgery but wants lid surgery for cosmesis, should I do lid surgery or counsel the patient and refer for decompression surgery first?
I have seen this ending up in disaster. If other surgeries (not following the sequence) are performed earlier and later if the the globe undergoes decompression surgery either by voluming down or opening spaces, whatever surgeries previously done- either to correct lid position or squint - completely misaligns the eye. an oculoplastics and starbismologist's nightmare it was cautioned. Not suggested to do so. And as you noted - the patient is cosmesis oriented so i personally wouldnt suggest to do so.
It depends upon the degree of proptosis. If there is none then can go with lid surgery provided eyelid retraction is the only existing sign (at least for 1.5 years not aN early one). If orbit is involved then decompression followed by other surgeries.
It depends upon the extent of eye involvement and type of strabismus. It would help if a picture is posted.
Hi Sabin. Generally, eyelid position changes after decompression. that is more remarkable for lower eyelids. Therefore, orbital decompression not only reduce the proptosis but also it can decrease eyelid retraction. From aesthetically point, patients with more than 2-3 mm proptosis especially if proptosis are asymmetric, patients are more likely to be unhappy if only eyelid retraction had been corrected. It is always helpful to review photographs before development of TED. You can estimate the norm of proptosis and eyelid position in the same patents. In my experience if the patient has a proptosis that needs correction even as small as 2-3 mm, decompression can more likely make the patient more happy than doing only eyelid job .
Hello Sabin living in this subcontinent I understand this question. In my practice I face this situation very often where patients are unwilling for a decompression but don't mind a small eyelid procedure. If there is symmetric mild proptosis and the eyelid retraction is significant in the absence of strabismus I have performed eyelid lengthening procedures with good success. Now all said and done although following decompression-strabismus-eyelid procedures is the norm worldwide, TED requires customisation based on various factors and you as a clinician can make the right decision for your patient based on the circumstances.
If significant proptosis then I would certainly go ahead for decompression first.