Combined endoscopic and subciliary orbital decompression for thyroid-related compressive optic neuropathy

Compressive optic neuropathy is a feared, although unusual, complication of thyroid-related orbitopathy. A variety of surgical approaches have been described to achieve orbital decompression and alleviate the hallmark apical orbital crowding of this condition. We describe a subciliary anterior orbitotomy approach to the floor combined with an endoscopic medial wall resection. The anterior orbitotomy allows removal of the bones of the orbital floor both medial and lateral to the canal of the infraorbital nerve. The anterior orbital floor is retained for globe support. This combined approach retains the low morbidity of the endoscopic operation while achieving increased apical medial orbital wall and orbital floor decompression. We describe two illustrative cases where this approach produced a dramatic improvement in visual function. The surgical refinements associated with this combined approach offer technical advantages over other operations in the treatment of thyroid-related compressive optic neuropathy.