What Is Orbital Decompression Surgery?

Our eyes are located in bony cavities within the skull known as orbits (eye sockets) (1). The orbital walls have a deep concave shape that serves as a cushion against blunt forces. This offers protection to the soft tissue of the eyes as well as allowing three-dimensional movement and neural communication. The orbit as a whole accommodates the eyes, fat, muscles, blood vessels, and nerves. The eyes can sometimes protrude out of the orbit and this condition is known as proptosis or exophthalmos, which by itself is not a disease, but rather a symptom of several underlying conditions. Exophthalmos causes increased pressure on the nerves and muscles in the orbital cavity and orbital decompression is a surgical procedure meant to relieve this increased pressure (2). Basically, the surgeon removes or thins parts of the eye socket (bones and/or orbital fat) to create more space, reducing pressure and easing the eye back into a more natural position.

When is Orbital Decompression Required

As mentioned above, protruding eyes are a sign of other underlying conditions and occur due to swelling, fat expansion, bone shifting, and/or inflammation, all of which can push the eye forward (proptosis). This leads to compression of the optic nerves, causing double vision (diplopia), pain, excessive tearing and exposure of the cornea. Some of the most common accompanying conditions that have exophthalmos as a symptom include:

• Thyroid eye disease (Graves’ orbitopathy): where swelling behind the eye(s) causes pain, bulging, and sometimes compression of the optic nerve.
• Optic neuropathy: when increased pressure on the optic nerve forms the threat of vision loss.
• Severe proptosis: excessive bulging out of the eyes to the extent that the eyelids are unable to close fully, causing corneal drying and increased risk of exposure damage.
• Trauma, tumors, or cysts (eg: retinoblastoma or metastatic neuroblastoma) in the orbit can displace eye structures.

The degree of proptosis varies from subtle to very severe and more serious cases, especially the ones involving pressure and risk of damage to the optic nerve usually warrant orbital decompression. The benefits can be significant with reduced pain/pressure, improved vision or prevention of vision loss, better eye appearance and reduced risk of exposure‐related eye damage.

Risks & Complications associated with Orbital Decompression Surgery

Orbital decompression surgery is one of the most effective procedures available for people with eye bulging (proptosis), most commonly due to thyroid eye disease (TED). It not only improves appearance but can also preserve vision, relieve eye pain and pressure, and protect the cornea. But understandably, patients will have concerns and it is important to satisfactorily alleviate all of them.

As with any major surgical procedure, orbital decompression also carries both generic and intervention-specific risks. But the caveat is that in patients who have serious symptoms with a high risk of vision loss, the potential benefits substantially outweigh those risks. Below are some of the specific risks and what you can (as a patient) do to reduce them.

Risk / Complication	How Common / Likely
Diplopia (double vision)	~10–30% depending on technique and disease severity
Swelling, bruising, edema	Very common and usually occurs immediately post-op. Usually resolves over weeks.
Bleeding / Hemorrhage	Generic risk which is present in all surgeries; more serious bleeding is less common.
Vision loss	Very rare
Cerebrospinal fluid (CSF) leaks / intracranial complications	Extremely rare
Numbness or altered sensation	Common in the area of surgery, (e.g. cheek, eyelid, nasal side) and is usually temporary.
Asymmetry / cosmetic dissatisfaction	Some level of asymmetry is possible and perfect symmetry is rare.
Infection	Uncommon, but the level of risk is the same as with any surgical procedure.
Other risks	Reaction to anesthesia, worsening preexisting motility issues, prolonged recovery, risk from systemic comorbidities like uncontrolled thyroid disease, bleeding disorders, etc.

Factors that Increase the Risk of Complications

Certain conditions or choices/extent of intervention are directly proportional to the chances of worse outcomes (3). Some of these include:

1. Extent of Decompression:

Removing more orbital walls (one, two, or three walls) increases the risk burden. More walls → greater anatomical complexity → higher the chance of affecting surrounding tissues or nerves.

2. Pre-existing Diplopia / Eye Muscle Issues:

If you already have misalignment or double vision, it’s more likely that surgery might worsen it. Studies show patients without significant preoperative diplopia have lower risk.

3. Having an Active Disease:

Undergoing surgery with active inflammation (e.g. active thyroid eye disease) is riskier. When the eyes and orbit are more swollen the tissues are more fragile, thereby making changes more unpredictable.

4. Other Systemic Health Issues and/or Comorbidities:

Bleeding disorders, uncontrolled thyroid disease, compromised immunity, or sinus disease can complicate surgery. Also, uncontrolled hypertension or poor management of anesthesia elevates the risks.

5. Surgeon Experience & Facilities:

As with any major surgical procedure, choosing an experienced surgeon who specializes in orbital/oculoplastic surgery (an oculoplastic surgeon) is important. Also, the center’s facilities, preoperative planning, and intraoperative techniques matter a lot.

Are Serious Complications Common?

Though there are no cases or procedures that are immune to risks or serious complications, to put that risk into perspective:

• Vision loss is very rare: studies estimate low percentages (often under 1%). For example, major vision-threatening events are uncommon in Graves’ disease decompressions (3).
• New or worsened double vision (diplopia): While some patients experience new or worsened double vision after decompression, it often settles and permanent diplopia is rare.
• CSF leak and intracranial complications: extremely rare with only a handful of cases being documented in literature.

But the important take-home message here is that the risk of severe permanent vision loss from decompression is extremely low and far lower than the risk of untreated TED causing irreversible damage in patients with optic nerve compression.

Risk Mitigation and Steps You Can Take to Minimize Them

If you are contemplating or preparing for orbital decompression, there are several ways to reduce risk and help make sure the procedure is as safe as possible.

• Thorough preoperative evaluation: imaging (CT/MRI), visual field tests, eye movement tests and checks for inflammation and/or active phase of disease.
• Manage risk factors: manage thyroid disease, control blood pressure, address sinus disease and avoid blood thinners as instructed.
• Choose a specialized, experienced oculoplastic/orbital surgeon: One who is qualified and has done many decompressions with favorable outcomes.
• Surgical planning: decide how many walls to decompress, whether to remove bone, fat, or both, weighing the benefits and risks. Sometimes it is prudent to phase the surgeries in terms of parts removed rather than all at once.
• Postoperative monitoring: early detection of complications like bleeding, infection, and vision changes. Ensuring you follow instructions for post-operative care (rest, avoiding strain, follow-ups) and promptly report any unusual symptoms

While these risks may sound concerning, for many patients with serious symptoms, especially threat to vision, optic nerve compression, or disfiguring proptosis, the benefits of orbital decompression often outweigh the risks. Blindness or permanent damage if left untreated, can be far worse than the minuscule risk of severe complications. Patients also often experience improved comfort, better ability to close the eyelids, less pain, reduced tearing and improved function. On the other hand, for patients with only mild disfigurement, without optic nerve involvement, or with active inflammation, the decision is more nuanced.

Bottom Line

So, is orbital decompression surgery dangerous? Yes, it carries risks, some serious. But those risks are rare and many of them exist for all major surgical procedures. If done by experienced surgeons, in carefully selected patients, with good preoperative planning, these risks are minimal vis-à-vis the pronounced benefits. For many people, especially those with moderate to severe disease, the potential to preserve vision, reduce pain, alleviate suffering, restore appearance, or prevent worse damage makes the surgery a good option. When performed by an experienced orbital specialist, such as Dr. Raymond Douglas, who routinely performs these procedures, orbital decompression has a very high safety profile and excellent success rates.

Being well-informed, asking the right questions, making sure your surgeon is qualified, and understanding the trade-offs are essential. If you are suffering from exophthalmos along with other symptoms like pain, vision problems and are considering orbital decompression, do not hesitate to schedule an appointment with Dr. Raymond Douglas.

References

1. Takahashi Y, Miyazaki H, Ichinose A, Nakano T, Asamoto K, Kakizaki H. Anatomy of deep lateral and medial orbital walls: implications in orbital decompression surgery. Orbit. 2013;32(6):409-12. Epub 20130924. doi: 10.3109/01676830.2013.833256. PubMed PMID: 24063541.
2. Rootman DB. Orbital decompression for thyroid eye disease. Surv Ophthalmol. 2018;63(1):86-104. Epub 20170324. doi: 10.1016/j.survophthal.2017.03.007. PubMed PMID: 28343872.
3. Sellari-Franceschini S, Dallan I, Bajraktari A, Fiacchini G, Nardi M, Rocchi R, Marcocci C, Marino M, Casani AP. Surgical complications in orbital decompression for Graves’ orbitopathy. Acta Otorhinolaryngol Ital. 2016;36(4):265-74. doi: 10.14639/0392-100X-1082. PubMed PMID: 27734978; PMCID: PMC5066461.