Abstract
Introduction
Compression eye patches are commonly used after orbital surgery to prevent retrobulbar hemorrhage and swelling. However, their necessity has not been established. This prospective study evaluates the efficacy of compression eye patches in postoperative care of orbital surgery following bilateral orbital fat decompression surgery.
Methods
This study included 64 patients (10 males, 54 females; mean age 41.25 ± 13.31 years) who underwent bilateral orbital fat decompression surgery for proptosis from October 2023 to February 2024. Fifty-eight patients had thyroid eye disease, and six had congenital bulging eyes. A compression eye patch was applied to the left eye for 2 h postoperatively, while the right eye remained untreated. Postoperative bruising, swelling, and complications were evaluated using a standardized scoring chart the day after surgery. Statistical analyses, including Student’s T-test and chi-squared tests, were performed to compare outcomes between the eyes.
Results
The mean fat removal was 3.18 ± 1.41 mL in the right eye and 3.45 ± 1.32 mL in the left eye (p = 0.27). Bruising color scores of Grade 2 or higher were noted in 48 right eyes and 46 left eyes (p = 0.83), while area scores were observed in 30 right eyes and 31 left eyes (p = 0.94). Swelling scores of Grade 2 or higher were identical in both eyes (14 cases, p = 0.98). No significant complications, including retrobulbar hemorrhage or subcutaneous hemorrhage, were observed.
Conclusion
Our findings suggest that postoperative compression eye patches may be unnecessary for post-orbital surgery care, as no significant differences were found between patched and unpatched eyes in the same patient.
Keywords: Orbital fat decompression, Compression eye patches, Retrobulbar hemorrhage, Vision loss, Postoperative care
Introduction
The application of compression eye patches is reported to minimize complications like retrobulbar and subcutaneous hemorrhage,1 but there are only a few reports on their usefulness for orbital surgery. Similarly, some studies advocate the use of cold packs for reducing postoperative edema.2,3 Orbital fat decompression surgery is a well-established procedure for treating thyroid eye disease,4 and it aims to relieve pressure in the eye socket by removing fat, thereby enhancing patient comfort and improving visual function. To evaluate the necessity and efficacy of employing compression eye patches for orbital surgery as a standard postoperative care measure, this study aims to examine whether the absence of compression eye patches compromises the postoperative outcomes, specifically focusing on the risks of retrobulbar and subcutaneous hemorrhage.
Orbital decompression surgery is a standard procedure for treating conditions such as thyroid eye disease.1 By alleviating orbital pressure, the surgery improves both functional and cosmetic outcomes, making it a critical intervention for patients with proptosis. Postoperative care traditionally includes the application of compression eye patches to minimize complications, such as retrobulbar hemorrhage, subcutaneous bruising, and swelling.2 Similarly, some studies advocate the use of cold packs for reducing postoperative edema.3,4
Despite their widespread use, the necessity and efficacy of compression eye patches for orbital surgery remain unclear. Compression eye patches may also introduce disadvantages, such as patient discomfort and the delayed detection of complications, including changes in visual acuity. To better understand the use of compression eye patches postoperatively, this prospective study investigates their role. Using a standardized scoring chart to evaluate bruising, swelling, and complications, we aimed to provide robust evidence on whether compression eye patches contribute to improved surgical outcomes or can be omitted without compromising patient safety. This study uniquely examines the need for postoperative compression patches in orbital surgery by comparing outcomes in the same patient’s patched and unpatched eyes, thus controlling for individual differences.
Methods
This prospective study enrolled Japanese individuals diagnosed with TED who underwent bilateral simultaneous orbital fat decompression surgery under general anesthesia between October 2023 and February 2024. The study adhered to the principles outlined in the Declaration of Helsinki, with all patients providing signed informed consent. The Institutional Review Boards of the Oculofacial Clinic Group approved the study protocol, and the study was registered with the Ethical Committee of the Oculofacial Clinic Group (Approval Number: 2023090101).
Only those patients who had undergone bilateral orbital fat decompression under general anesthesia concurrently were included. Exclusion criteria were patients with a history of orbital or lower eyelid surgery and patients who had undergone other concomitant surgeries.
Surgical procedure
All surgeries were performed under general anesthesia as day-case procedures, with both eyes operated on simultaneously. The surgery was performed by several experienced ophthalmic surgeons affiliated with our institution, each using a transconjunctival approach. A lower eyelid conjunctival incision was utilized to access the orbital fat. Thorpe forceps were specifically used to isolate and remove the excess fat. Both superficial and deep-seated orbital fat were targeted, but the emphasis was mainly on the removal of deep-seated fat. No sutures were applied; the surgical sites were meticulously managed to allow for sutureless closure.
Postsurgical care
After undergoing bilateral orbital fat decompression surgery under general anesthesia, all patients were instructed to rest in the recovery room for 2 h before being discharged home. Postoperative care protocols varied depending on the eye:
Right Eye (without a compression eye patch): No compression eye patch was applied. Left Eye (with a compression eye patch): A compression eye patch was applied immediately after surgery and left in place for 2 h.
The patient's photo at the end of the surgery is shown in Figure 1. The patients were instructed to continue bed rest as much as possible and apply cold packs for both eyes to minimize swelling until the next morning. An antibiotic ointment was applied to the conjunctival wound immediately after surgery and the next day. Follow-up assessments were conducted the day after surgery, 1 week later, and one month later to monitor recovery, wound healing, and any potential complications.
Figure 1.
The right eye had no patch and the left eye had a compression patch.
Study procedures
This study aimed to compare postoperative outcomes between the left eye (with a compression eye patch) and the right eye (without a compression eye patch) in patients undergoing bilateral orbital fat decompression surgery. The comparison focused on three key dimensions of postoperative recovery (Table 1): changes in skin color, the extent of bruising, and eyelid swelling. These parameters were assessed on a standardized scale to evaluate the severity and recovery progression following surgery. Postoperative outcomes were evaluated on the day after surgery. MRD-2 distances were measured using Image J software (version 1.53).
1. Skin color changes
Table 1.
Scoring chart.
| Score | 0 | 1 | 2 | 3 |
|---|---|---|---|---|
| Color | No change | Yellow | purple | Red or black |
| Range | No change | Only lower eyelid | Beyond the orbital margin or subconjunctival hemorrhage | Extend to the upper eyelid |
| Eyelid tension | No tension | Mild tension (MRD-2 change is 1–2 mm compared to pre-operation) | Moderate tension (MRD-2 change is ≧3 mm compared to pre-operation) | Severe tension (MRD-2 change is ≧3 mm compared to pre-operation and it is difficult to open eyelid) |
Postoperative changes in skin color were assessed and categorized into three grades: Grade 1 for yellow discoloration, Grade 2 for purple discoloration, and Grade 3 for red/black discoloration. This grading provided a clear indication of the extent and severity of subcutaneous hemorrhage.
2. Extent of bruising
The range of bruising was evaluated based on the area affected. Grade 1 was assigned for bruising confined to the lower eyelid, Grade 2 for bruising extending beyond the orbital margin or with subconjunctival hemorrhage, and Grade 3 for bruising extending to the upper eyelid.
3. Eyelid swelling
Eyelid swelling was assessed by measuring changes in marginal reflex distance 2 (MRD-2), defined as the distance from the center of the pupil to the lower eyelid margin in the primary gaze. Swelling severity was graded as follows: Grade 1 for mild swelling (MRD-2 change of 1-2 mm), Grade 2 for moderate swelling (MRD-2 change ≥3 mm), and Grade 3 for severe swelling (MRD-2 change ≥3 mm with difficulty opening the eyelid).
All assessments were conducted by a single evaluator who was blinded to the surgical procedure to ensure unbiased comparisons between the left and right eyes. Additionally, we evaluated postoperative complications.
Statistical analysis
Data analysis was conducted using JMP® Pro 17.2.0 (SAS Institute Inc., Cary, NC, USA). A Student's T-test was performed to determine significant differences in the amount of fat excised between the right and left eyes. A chi-squared test was used to determine whether the scores for the left and right eyes were independent.
Results
A total of 64 patients (10 males, 54 females; mean age 41.3 ± 13.3) were enrolled in this prospective study, including 58 patients with thyroid eye disease and 6 patients with congenital ocular proptosis. None of the patients had a history of bleeding disorders or were on antithrombotic medications.
The amount of orbital fat resection in both eyes was 3.18±1.41 mL in the right eye and 3.45±1.32 mL in the left eye, with no significant difference (p = 0.27). When scoring the color of the internal hemorrhage on the day after surgery, 48 patients had a Grade 2 or higher in the right eye and 46 in the left eye. For area scoring, 30 patients had Grade 2 or higher in the right eye and 31 patients had Grade 2 or higher in the left eye. Eyelid swelling scoring for Grade 2 or higher was 14 in the right eye and 14 in the left eye. In particular, the scoring for eyelid swelling was often 0 or 1. There was no significant difference in color, area of bruising, or degree of swelling between the two groups (p = 0.83, 0.94, 0.98) (Table 2). No major postoperative complications, such as post-spherical hemorrhage or significant subcutaneous hemorrhage, were observed. No patients developed new onset diplopia in primary position or severe visual acuity or visual field defects. Figure 2 show preoperative and postoperative photographs of three patients.
Table 2.
Results.
| Complication outcomes | Right eye (n) | Left eye (n) | p-value |
|---|---|---|---|
| Color (Score) | 0.95 | ||
| 0 | 0 | 0 | |
| 1 | 16 | 18 | |
| 2 | 45 | 42 | |
| 3 | 3 | 4 | |
| Range (Score) | 0.95 | ||
| 0 | 0 | 0 | |
| 1 | 34 | 33 | |
| 2 | 25 | 25 | |
| 3 | 5 | 6 | |
| Tension of eyelid (Score) | 0.98 | ||
| 0 | 18 | 20 | |
| 1 | 32 | 30 | |
| 2 | 9 | 9 | |
| 3 | 5 | 5 |
Figure 2.
Pre- and post-operative photos.
Discussion
This prospective study evaluated 64 patients (128 orbits) who underwent bilateral orbital fat decompression surgery, comparing postoperative outcomes between eyes with and without compression eye patches. The results revealed no significant differences in complications, bruising, swelling, or wound healing between the two groups, suggesting that compression eye patches may not be necessary in postoperative care.
Previous studies have highlighted the potential for retrobulbar hemorrhage following orbital surgeries, with reported incidences ranging from 1.2 %–3.2 % after orbital fracture repair.5,6 The incidence of blindness after orbital decompression has been reported to be 0 %–0.84 %.7, 8, 9, 10, 11, 12 However, our study found no cases of retrobulbar hemorrhage or other major complications, including vision loss or significant subcutaneous hemorrhage, in either group. This aligns with findings that compression eye patches may not effectively prevent deep orbital bleeding, as the primary sources of hemorrhage in orbital surgery are often located posterior to the globe, beyond the reach of external compression.
Additionally, compression eye patches have potential drawbacks, including patient discomfort and delayed detection of vision changes. By omitting these patches, patients in our study reported a higher level of comfort without compromising safety. The use of cold packs alone effectively minimized swelling and bruising, supporting the feasibility of omitting compression eye patches.
The use of a standardized scoring chart and the direct comparison of treated and untreated eyes within the same patients provided an unbiased assessment. This methodology eliminated individual variability, strengthening the reliability of our findings.
While the present study focuses on the functional benefits of compression eye patches in orbital decompression surgery, tissue-preserving approaches have gained attention in the field of cosmetic lower eyelid surgery. Sam Hamra proposed a technique to preserve and reposition orbital fat across the arcus marginalis, aiming to prevent the sunken appearance associated with conventional fat removal.13 Similarly, Helga Eder reported favorable aesthetic outcomes in over 200 cases of lower blepharoplasty performed with fat conservation and redistribution, highlighting the anatomical and structural importance of orbital fat.14 Although the surgical objectives differ, both fields emphasize the relevance of soft tissue handling in achieving optimal outcomes.
Despite these promising results, our study has limitations. While the sample size is larger than previous studies, it remains relatively modest, and the inclusion of a single demographic (Japanese patients) may limit generalizability. Furthermore, the short follow-up period may not capture rare or late-onset complications. Larger, multicenter studies with longer follow-up periods are necessary to validate these findings and refine postoperative care protocols for orbital fat decompression surgery.
Conclusion
Compression eye patches do not significantly influence postoperative outcomes in orbital fat decompression surgery. Omitting them enhances patient comfort without increasing risks, suggesting a shift in traditional care protocols.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Data sharing statement
The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.
Ethics approval
This study was approved by the Ethical Committee of the Oculofacial Clinic Group (Registration ID: 2023090101).
Informed consent
Written informed consent was obtained from the patients for participation in this study and for the publication of this case report and the accompanying images.
Author contributions
Study conception and design: Tomoyuki Kashima. Acquisition of data: Ryo Kikuchi. Analysis and interpretation of data: Ryo Kikuchi. Drafting of the manuscript: Ryo Kikuchi.
Disclosure
The authors report no conflicts of interest in this work.
Acknowledgments
We would like to thank Ron Beaubien sincerely for his invaluable support and guidance throughout this study.
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