Postoperative Care of the Endoscopic Orbital Decompression Patient





Postoperative treatment of patients undergoing endoscopic orbital decompression (EOD) shares many similarities with that of patients who have standard functional endoscopic sinus surgery. Important distinctions that must be accounted for relate to the herniation of orbital contents into the nose and specific potential complications. Potential orbital complications include corneal abrasion, epiphora, new or worsening diplopia, worsening vision, and vision loss. Potential sinus complications include postoperative hemorrhage, obstructive sinusitis, nasal obstruction, anosmia, infraorbital nerve hypoesthesia, and cerebrospinal fluid (CSF) leak. An understanding of these possible sequelae is essential to treating these patients postoperatively.


Perioperative considerations, postoperative management, and the rate of complications are influenced by the indication for EOD. The majority of decompressions are performed for the sequelae of Graves ophthalmopathy, including proptosis with aesthetic concerns, exposure keratitis, strabismus/diplopia, and compressive optic neuritis (CON). Other indications include orbital cellulitis/abscess, retrobulbar hematoma/hemorrhage, and traumatic optic neuropathy. These patients are best managed through a multidisciplinary approach consisting of otolaryngology, ophthalmology, and endocrinology specialists. The goals of surgery, expected outcomes, and risks for short- and long-term complications are determined based on the extent of disease and the indication for the procedure.


Perioperative


Preoperative


A baseline preoperative assessment of corrected visual acuity, pupillary examination, ocular motility, intraocular pressure, fundus examination, and Hertel exopthalmometry is required to compare postoperative vision status and orbital outcomes. A comprehensive assessment of sinonasal history, examination, and imaging is essential. The presence or history of sinonasal disease is associated with an increased likelihood of developing postoperative obstructive sinusitis.


The preoperative period represents an opportunity to counsel patients regarding their specific surgical indication and to guide patient expectations for the postoperative course. The goal of EOD for proptosis is to improve cosmesis without causing diplopia, requiring a more balanced and less aggressive approach. Patients with preoperative diplopia/strabismus should be counseled that this may worsen, remain the same, or improve postoperatively. The chance of requiring future strabismus surgery is higher in this population.


Patients undergoing EOD for exposure keratitis require a greater degree of orbital regression, elevating their risk for postoperative diplopia. Continued conservative management of their exposure keratitis is required in the initial postoperative period until orbital swelling resolves. A temporary tarsorrhaphy may be required in these cases.


EOD for CON focuses on decompressing the posterior lamina papyracea and orbital apex. These patients have less orbital regression and are less likely to develop postoperative diplopia. The risks of worsening vision, vision loss, and CSF leak are higher in these patients, particularly if optic nerve decompression is performed. CON patients require a multidisciplinary team to provide comprehensive medical management, including the optimization of postoperative steroid and thyroid disease management.


Intraoperative


Specific intraoperative techniques can decrease the rate of postoperative obstructive sinusitis, new or worsening diplopia, and hemorrhage. Wide maxillary antrostomies and sphenoidotomies should always be performed, and the lamina papyracea near the frontal recess should be preserved. Preservation of an inferior medial bony or periorbital strut has been shown to decrease the incidence of new or worsening postoperative diplopia. A balance between obtaining maximal orbital regression without causing new or worsening diplopia should be the goal, particularly when the indication for surgery is proptosis or cosmesis.


Meticulous intraoperative hemostasis with the assistance of bipolar cautery and absorbable hemostatic agents is essential. Rigid nonabsorbable packing should be avoided in the intraoperative and postoperative setting, as it can lead to excessive tamponade pressure on the exposed orbital soft tissues. Emergence from anesthesia should be gentle, and positive-pressure ventilation should be avoided, as it can induce subcutaneous or intraorbital emphysema.


Postoperative


Visual vital signs (acuity, pupillary reflex, motility, and intraocular pressure) should be obtained as soon as possible postoperatively and followed closely in the surgical recovery unit. Any patient-reported change in vision should be investigated promptly. Cool compresses are used to assist with orbital swelling and improve patient comfort.


Patients with episodes of refractory severe postoperative hemorrhage should undergo definitive operative control with the assistance of bipolar cautery and absorbable hemostatic agents. Monopolar cautery has the potential to transmit electrical impulses to intraocular structures, potentially inducing myopathy or neuropraxia, whereas rigid nonabsorbable packing has the potential to tamponade the orbit and raise intraocular pressure. Both should be avoided when treating postoperative hemorrhage in the setting of EOD.


Discharge


Patients are candidates for discharge once it is determined that their vision is stable, that they have adequate hemostasis, and that they do not have any other postoperative barriers to discharge. Based on surgical team preference, orbital decompression patients can either be discharged later on the day of surgery or observed overnight. Those also undergoing optic nerve decompression are monitored overnight. If a patient is sent home the same day, follow-up with ophthalmology should be scheduled the following morning for a formal vision examination. The surgical team should be informed immediately of any vision changes or episodes of significant epistaxis that occur after discharge.


Discharge instructions should include sinus precautions (avoid nose blowing, sneeze with mouth open, and avoidance of heavy lifting or straining), initiation of a nasal saline regimen, and continuation of cool compresses for the eyes. Although twice-daily gentle positive-pressure saline irrigations can be initiated, the authors’ practice is to use saline mist (2 sprays every 1 to 2 hours while awake) for the first postoperative week.


A combination antibiotic and steroid ophthalmic ointment should be continued after discharge. Nasal steroids are not required. Definitive data regarding the need for postoperative oral antibiotics in EOD patients have not been reported, and a consensus has not been developed. The authors’ practice is to empirically prescribe a single intraoperative intravenous antibiotic dose and a postoperative 10-day oral antibiotic course covering Staphylococcus aureus . Postoperative steroids are typically required for patients with CON and for patients undergoing optic nerve decompression. Management of steroid dosages requires a multidisciplinary approach and should be based on individual patient factors.


Follow-up


After discharge, patients continue close follow-up with their multidisciplinary team. Visual acuity, degree of recession, and diplopia are assessed by an ophthalmologist. The reported incidence of new or worsening postoperative diplopia has not been definitively defined owing to the variability of surgical indications and techniques. Stable, new, or worsening postoperative diplopia is monitored for 9 to 10 months. For patients in whom diplopia does not resolve, definitive strabismus surgery should be considered.


Patients are seen by an otolaryngologist at 1 week postoperatively for an initial debridement. Early debridement requires great care and diligence to avoid injuring the intranasally exposed orbital contents. Palpation of the orbit is performed during debridement to help delineate the intranasal orbital contents. The frequency of future debridement is determined based on the severity of crusting. During the natural healing process, the intranasal orbital fat begins to atrophy and the orbital contents eventually solidify and mucosalize ( Figs. 23.1 and 23.2 ). Once the mass movement of the intranasal orbital contents stabilizes, more definitive debridement of crusting can be pursued. Gentle nasal saline irrigations, which are initiated after the first week postoperatively, should be continued until crusting stops.


Jan 3, 2021 | Posted by in OPHTHALMOLOGY | Comments Off on Postoperative Care of the Endoscopic Orbital Decompression Patient
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