Orbital Surgery Instructions

Patient information document for patients undergoing orbital surgery. This includes the following procedures:

• Orbital decompression surgery for thyroid eye disease (TED)
• Orbital Exploration and Biopsy
• Orbital trauma repair
• Orbital surgery in general

INSTRUCTIONS

This is an informed consent document that has been prepared to help you understand the procedures mentioned above and their risks. It is important that you read this information carefully and completely.

Section A provides a brief outline of the procedures. Section B outlines the general risks associated with orbital surgery. The surgical plan is individually tailored for every patient, your surgeon will discuss the risks more relevant to your procedure.

SECTION A

ORBITAL DECOMPRESSION SURGERY

The primary goal of an orbital decompression surgery is to correct the forward bulging of the eyes (proptosis) by creating more space around the eye socket (orbit) to allow the eye to return to a more normal position. This space is created by removing bone from the eye socket walls. The operation is customized for individual patients and depending on the severity of the proptosis one, two or three walls may need to be removed. In most patients a small amount of eye socket fat may also have to be removed to achieve the desired results. A few patients with a very small amount of proptosis may only require fat removal. The other reasons for performing an orbital decompression include:

• Sight threatening pressure on the optic nerve (Compressive optic neuropathy)
• Inability to close the eyes due to proptosis that results in severe drying of the eyes (Exposure keratopathy)
• Eyeball popping out of the socket (spontaneous globe prolapse)
• Disfigurement
• Discomfort due to orbital pressure/pain
• Orbital congestion (Hydraulic TED)

ORBITAL EXPLORATION AND BIOPSY

A variety of problems such as swelling, inflammation, or the presence of a mass or tumor may necessitate an orbital exploration procedure. Sometimes this procedure may be performed to drain an abscess from within the eye socket or even remove a foreign body. The purpose of the operation may be to get a diagnosis or remove the mass or perhaps both.

ORBITAL TRAUMA REPAIRE

Severe trauma to the upper face can result in fracture of the eye socket bones. If not repaired these fractures may result in the eye sinking into the eye socket and/or permanent double vision.

ARE THERE ANY ALTERNATIVES TO SURGERY?

In some patients, orbital surgery is necessary to make a diagnosis, fix a fracture or to preserve sight. If the procedure is being performed to reduce proptosis (decompression), remove a tumor or obtain a tissue sample and you decide not to proceed, the appearance of the eyes and symptoms are unlikely to improve spontaneously. They may stabilize or even worsen over time.

If you have any specific concerns, you should discuss them with your doctor.

SECTION B

GENERAL RISKS OF ORBITAL SURGERY

Every surgical procedure involves a certain amount of risk, and it is important that you understand the risks involved. You then have to compare these risks to the potential benefits for you. Although the majority of patients do not experience the following complications, you should discuss each of them with your surgeon to make sure you understand the risks, potential complications, and consequences of orbital surgery.

ASYMMETRY

The human face and eyelid region is normally asymmetrical. There is always some variation from one side to the other following surgery. Perfect symmetry cannot be achieved and is not the aim of surgery.

ALLERGIC REACTIONS

In rare cases, local allergies to tape, suture material, or topical preparations have been reported. Systemic reactions that are more serious may occur to drugs used during surgery and prescription medicines. Allergic reactions may require additional treatment.

BLEEDING

It is possible, though unusual, to have significant bleeding during or after surgery. Bleeding may occur under the skin or internally around the eyeball. Should you develop significant post-operative bleeding, it may require emergency treatment or surgery. Do not take any aspirin, anti-inflammatory medications like Ibuprofen, garlic or ginseng for ten days before surgery, as this may contribute to a greater risk of a bleeding problem. Inform your doctor if you take any medications to thin the blood, like Warfarin, Clopidogrel or Plavix. Hypertension (high blood pressure) that is not under good medical control may cause bleeding during or after surgery. Accumulations of blood under the eyelids may delay healing and cause scarring.

LOSS OF VISION

This is uncommon after orbital surgery. The relative risk depends on the type of orbital procedure. Internal bleeding around the eye during or after surgery can cause this. It can also occur as a consequence of a spasm of the blood supply to the eye or the optic nerve. The occurrence of this is not predictable.

BRUISING & SWELLING

All patients get bruising and swelling after surgery. This can take up to 2-3 weeks or longer to settle. Very uncommonly it may take longer.

CHEMOSIS

Very occasionally a jelly like swelling of the conjunctiva (the white of the eye) can occur after orbital surgery. This usually settles down spontaneously after a few weeks. The occurrence of this is not predictable.

CHRONIC PAIN

Chronic pain may occur very infrequently after surgery.

CORNELA EXPOSURE PROBLEMS

Some patients experience difficulties closing their eyelids after surgery and problems may occur in the cornea due to dryness. Should this rare complication occur, additional treatments or surgery may be necessary.

DAMAGE TO DEEPER STRUCTURES

The potential for this to occur varies with the type of procedure performed but is very uncommon. Deeper structures such as nerves, blood vessels, and eye muscles may be damaged during the course of surgery. Injury to deeper structures may be temporary or permanent. This may manifest as altered sensations, drooping of an eyelid or as double vision.

DELAYED HEALING

Wound disruption or delayed wound healing is possible. Very rarely there can be persistent swelling that can last several months or more. This is caused by non-healing or scarring of the lymphatic drainage system.

DRY EYE PROBLEMS

Occasionally patients notice dryness or grittiness of the eyes for a few days after surgery. You may be given lubricating eye drops for a week to ten days after surgery. Permanent disorders involving decreased tear production and evaporation can occur after some types of orbital surgery. The occurrence of this is rare and not entirely predictable. Individuals who normally have dry eyes may experience a temporary or permanent worsening of symptoms.

DOUBLE VISION

Orbital surgery often requires manipulation of the muscles that move the eye. This can result in temporary double vision that may last up to three months. Very uncommonly the double vision may be permanent and require additional surgery to correct.

INFECTION

Infection is very rare after surgery. Should an infection occur, additional treatment including antibiotics might be necessary.

NUMBNESS (altered sensation of cheek, lip or eyelids)

During orbital surgery it is often necessary to move nerves (when fixing fractures, performing decompression surgery or removing tumours). This causes a temporary loss or alteration of the nerve’s function, which can take several months to recover. Very occasionally a nerve may have to be sacrificed during surgery. This results in a permanent loss of sensation to the affected area.

SCARRING

All surgical incisions leave a scar. Whilst most scars fade within a few weeks of surgery, others can be hidden in skin creases, hairline etc. so as to be almost invisible. Although good wound healing after a surgical procedure is expected, abnormal scars may occur both within the eyelid and deeper tissues. All scars are slightly pale / pink for up to six months. This difference in color can be exaggerated if you spend a lot of time in the sun. In rare cases the scars may be bulky and of different color than the surrounding skin.

UNSATISFACTORY RESULT

There is the possibility that the result of your surgery is not as expected. Surgery may result in visible deformities, loss of function, wound disruption, and loss of sensation. If necessary additional surgery can be performed to improve your results.

RARELY

Due to the very close proximity of the brain to the orbit, a temporary cerebrospinal fluid leak (leakage of fluid of the brain) may occur during surgery. Extremely rarely, a fatal brain hemorrhage can also occur. Even though risks and complications occur infrequently, the risks cited are the ones that are particularly associated with the procedures listed at the beginning of the document.