Predictive Modeling of New-Onset Postoperative Diplopia Following Orbital Decompression for Thyroid Eye Disease

Archana A. Nair, Lilangi S. Ediriwickrema, Peter J. Dolman, Geoffrey Law, Andrew R. Harrison, Ali Mokhtarzadeh, Krista Stewart, Clara Men, Mark J. Lucarelli, Suzanne Van Landingham, Maxwell Wingelaar, Rohan Verma, Allison Chen, Dinesh Selva, James Garrity, Laurence Eckel, Michael Kazim, Kyle Godfrey, Sally L. Baxter, Bobby S. KornDon O. Kikkawa

Research output: Contribution to journalArticlepeer-review

5 Scopus citations


PURPOSE: To identify risk factors for the development of new-onset, postoperative diplopia following orbital decompression surgery based on patient demographics, clinical exam characteristics, radiographic parameters, and surgical techniques.

METHODS: We conducted a multi-center retrospective chart review of patients who underwent orbital decompression for thyroid eye disease (TED). Patient demographics, including age, gender, smoking history, preoperative exophthalmometry, clinical activity score (CAS), use of peribulbar and/or systemic steroids, and type of orbital decompression were reviewed. Postoperative diplopia was determined at a minimum of 3 months postoperatively and before any further surgeries. Cross-sectional area ratios of each extraocular muscle to orbit and total fat to orbit were calculated from coronal imaging in a standard fashion. All measurements were carried out using PACS imaging software. Multivariable logistic regression modeling was performed using Stata 14.2 (StataCorp, College Station, TX).

RESULTS: A total of 331 patients without preoperative diplopia were identified. At 3 months postoperatively, 249 patients had no diplopia whereas 82 patients developed diplopia. The average postoperative follow-up was 22 months (range 3-156) months. Significant preoperative clinical risk factors for postoperative diplopia included older age at surgery, proptosis, use of peribulbar or systemic steroids, elevated clinical activity score, and presence of preoperative compressive optic neuropathy. Imaging findings of enlarged cross-sectional areas of each rectus muscle to the overall orbital area also conferred a significant risk of postoperative diplopia. Regarding surgical factors, postoperative diplopia was more common among those undergoing medial wall decompression, bilateral orbital surgery, and balanced decompression, whereas endoscopic medial wall decompression was found to be relatively protective.

CONCLUSIONS: This study identifies risk factors associated with the development of diplopia following orbital decompression using multivariable data. This study demonstrates that several characteristics including age, clinical activity score, the cross-sectional muscle to orbit ratios, in addition to the type of orbital decompression surgery, are predictive factors for the development of new-onset postoperative diplopia.

Original languageEnglish (US)
Pages (from-to)551-557
Number of pages7
JournalOphthalmic Plastic and Reconstructive Surgery
Issue number6
Early online date2022
StatePublished - Nov 1 2022

Bibliographical note

Funding Information:
Supported by the Bell Charitable Foundation, Rancho Santa Fe, CA; Research to Prevent Blindness, New York, NY.

Publisher Copyright:
© 2022 Lippincott Williams and Wilkins. All rights reserved.

PubMed: MeSH publication types

  • Journal Article


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