title: Surgical strategy in the treatment of globe protrusion depending on its mechanism (Graves' disease, nonsyndromic exorbitism, or high myopia).
abstract: BACKGROUND
  Graves' ophthalmopathy affects orbital contents and eyelids. Protrusion of the globe can also be the result of myopia and/or an abnormal orbit shape, which is responsible for nonsyndromic exorbitism. It is necessary to recognize these components of protrusion to treat patients adequately. The authors present a surgical strategy for treatment of the orbit and lids.
  
  
  METHODS
  Files of 84 patients treated from 1984 to 2003 were retrospectively reviewed. Sixty-eight patients were operated on for Graves' ophthalmopathy and 16 for nonsyndromic exorbitism with or without myopia. The surgical strategy was adapted to the degree of emergency, the age of the patient, and the shape of the orbit measured using computed tomography. The accepted standard of treatment was a coronal approach with a two-wall expansion, with or without bone grafts, especially in cases of associated nonsyndromic exorbitism, with or without complementary ablation of the external part of the orbital floor. Lid surgery was performed at a second stage.
  
  
  RESULTS
  Nonsyndromic exorbitism patients were successfully treated in one step. No diplopia was present either preoperatively or postoperatively. In contrast, the treatment of the Graves' ophthalmopathy patients justified one to three orbital expansion procedures per patient and/or one to seven procedures for levator palpebrae lengthening or reinsertion. Forty-three percent of preexisting diplopias were improved by the surgery. The overall postoperative incidence of de novo diplopia was 19 percent. In the Graves' ophthalmopathy series, three patients (5 percent) finally underwent strabismus surgery. No major complication occurred.
  
  
  CONCLUSIONS
  The treatment of Graves' ophthalmopathy is challenging. A graded approach is justified. Patients have to be informed that several procedures may be necessary and, in cases of nonsyndromic exorbitism or myopia, that facial modifications might occur.
authors.affiliation: Department of Head and Neck Surgery, Hôpital Foch, Suresnes, France.
authors.forename: Darina
authors.initials: D
authors.lastname: Krastinova-Lolov
authors.forename: Christine A
authors.initials: CA
authors.lastname: Bach
authors.forename: Dana M
authors.initials: DM
authors.lastname: Hartl
authors.forename: Francois
authors.initials: F
authors.lastname: Coquille
authors.forename: Michel
authors.initials: M
authors.lastname: Jasinski
authors.forename: Patricia
authors.initials: P
authors.lastname: Cecchi
authors.forename: Bertrand
authors.initials: B
authors.lastname: Baujat
mesh_terms: D000465:Algorithms; D016025:Bone Transplantation; D005143:Eyelids / Q000601:surgery*; D049970:Graves Ophthalmopathy / Q000601:surgery*; D006801:Humans; D009216:Myopia / Q000150:complications / Q000601:surgery; D009801:Oculomotor Muscles / Q000601:surgery; D013508:Ophthalmologic Surgical Procedures / Q000379:methods*; D009915:Orbit / Q000601:surgery*; D012189:Retrospective Studies; D015361:Rhytidoplasty