Cerebral and optic nerve complications following bony orbital decompression for Graves' orbitopathy. A systematic review.

PURPOSE: To perform a systematic literature review on major complications of orbital decompression and describe our experience with three new unpublished cases.

METHODS

The PubMed and Embase databases were searched using the keywords ("orbital decompression") AND (Graves) or (thyroid eye disease) in January 2025. Only articles in English, Spanish, or French were included. Major complications were defined as cerebrospinal fluid leaks, intracranial complications, and vision loss. The authors also reviewed all medical records of patients who underwent orbital decompression over 34 years (1990-2024) for Graves' orbitopathy at the teaching hospital of the School of Medicine of Ribeirão Preto, Brazil.

RESULTS

Cerebrospinal fluid leaks occurring during medial and lateral decompressions have been reported in 22 articles, with an estimated rate ranging from 1.0% to 2.0%. Several severe neurological side effects were reported in 14 articles, most occurring during medial decompression. Blindness after orbital decompression was documented in nine papers as a multifactorial event.

CONCLUSIONS

The surgical factors involved in major complications associated with orbital decompression have not been discussed in detail. The analysis of the three new cases, along with those cited in the literature, shows that careful multiplanar radiological reconstruction of the olfactory fossa and posterior ethmoid pneumatization is an essential step to avoid intracranial complications during medial decompression. In deep lateral decompressions, the risk of major complications is minimized with careful bleeding control and avoidance of dural exposure.