Choice of surgical treatment for Graves' disease.

Functional and cosmetic ophthalmic complications of Graves' (1835) disease are dysthyroid optic neuropathy, exophthalmos, eyelid retraction and oculomotor disturbances. This paper describes and elaborates on the surgical procedures used when these complications are present. In severe exophthalmos and optic neuropathy we use an orbital decompression of the orbital floor sometimes combined with the medial wall, via an anterior approach. In eyelid retraction, we perform a recession of the levator muscle with scleral graft implantation. In concomitant strabismus, surgery is usually limited to recessions of the involved muscles, most of the surgery is directed to the inferior and medial rectus, as these are the most commonly affected muscles. The indications depend on the status of the patient at the time of referral. For severe exophthalmos with true retraction of the upper eyelid, we begin by treatment of the retraction and if this is not sufficient, we perform orbital decompression. For severe exophthalmos with oculomotor disturbances, we perform orbital decompression and later, the strabismus surgery. For oculomotor disturbances with eyelid retraction, we perform the strabismus surgery at the first and the eyelid retraction at the second stage. When there is a combination of exophthalmos, eyelid retraction and oculomotor disturbance, the indications and the choice of treatment are difficult and depend on numerous factors. If orbital decompression is indicated, it will be done first, followed by the strabismus surgery and at a later stage, the eyelid retraction. If only the eyelid retraction is treated, it will be done after the strabismus surgery. The chronological order of treatment depends on the modification we observe on the other components of the ophthalmopathy.