A 46-year-old woman was referred to the Oral and Maxillofacial Surgery Department of the Ophthalmology Department for evaluation and treatment of her exophthalmos.
His personal history included hypertension, morbid obesity and iodine allergy.
In 1980, she was diagnosed with hyperthyroidism caused by Graves-Basedow disease. She underwent surgery two years later, performing subtotal thyroidectomy, and 50 mg/day of treatment was prescribed.
In 1999, the patient came to the Ophthalmology Department complaining of slow but progressive worsening of the exophthalmos, as well as signs and symptoms of hoarseness.
After treatment with steroids and radiotherapy is rejected, the patient underwent surgical closure (medial walls and floor) of the left eye by means of the megacolon approach.
Total thyroidectomy was performed in March 2002.
In June 2003, the patient attended our consultation presenting severe vestibular retraction, more pronounced in the external or temporal third of the upper eyelid; the superior corneal limbus area is exposed by limbus, leaving a limbal zone exposed by
Hypertrophy of the suborbicular fat of the lower eyelid region was observed.
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Exophthalmos is evident, which is bilateral.
The patient complained of inability to keep reading for a long time, with fatigue and discomfort, symptoms of restricted ocular motility.
The disease is in a non-inflammatory phase, without severe stenosis, hyperemia, conjunctival chemosis or diplopia.
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The orbital CT showed exophthalmos, muscle thickening, increased orbital fat volume and optic nerve rectification.
It has the advantage of MRI that shows details, which are of great value for planning surgical procedures for decompression.
MRI shows exophthalmos with severe muscle thickening with increased ventral portion and adipose tissue.
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With the described background, clinical and imaging tests, surgical treatment was decided by partial removal of the lateral wall and orbital floor, along with lipectomy and osteotomy with advancement of the superior, lateral and inferior orbital framework.
A bicoronal approach was performed, with a subgaleal flap up to approximately 2 cm from the supraorbital margin, where an incision of the periosteum was made and the periorbital plane was continued.
The anterior portion of the temporal muscle was released from its insertion to allow better access to the lateral orbital wall.
The approach was completed with a bilateral subcortical incision that allowed access to the infraorbital rim and the medial region of the orbital floor.
We performed bilateral osteotomy -orbitotomy- of the superior, lateral and inferior orbital framework, advancing 8 mm from its original position.
Osteosynthesis was performed with 2.0 miniplates.
It proceeds to the removal of the lateral orbital wall and soil in its medial and lateral portion, respecting the course of the infraorbital nerve.
Periorbital incisions and lipectomy were performed after release of periorbital fat.
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A subgaleal aspiration drainage was placed and removed 48 hours later.
A temporary tarsorrhaphy (Frost point) was maintained for the first 48 hours.
At 72 hours, the patient developed severe pain in the posterior region of the left atrium, which was diagnosed as thrombosis of the twin lake and treated with heparin.
Submerged suture was removed at 5 days and coronal suture at 10 days.
