This review of surgical decompression in patients with dysthyroid orbitopathy concluded that no intervention was superior. This conclusion reflected a lack of evidence rather than robust evidence of no difference, which suggested that further research was necessary.

To evaluate the effects of surgical decompression in patients with dysthyroid orbitopathy.

PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Database of Systematic Reviews were searched for English-language publications from January 1990 to April 2008. Topic-specific search terms were reported. Reference lists of publications were searched.

Controlled studies and retrospective case series of five or more decompressed orbits were eligible for inclusion. Eligible studies were classified by intervention: endoscopic endonasal, transantral, external, minimal access and combined techniques.

The most common outcome measures were reduction in proptosis and improvement in visual acuity. Adverse effects and postoperative diplopia were catalogued. Patient age ranged from 14 to 83 years old. Follow-up ranged from one week to 160 months.

Two reviewers performed the study selection.

Internal validity of eligible studies was not appraised. Levels of evidence grades as defined by the Oxford Centre for Evidence-Based Medicine were defined.

Number of patients, sex and outcomes measured were extracted for each study. Total number of orbits decompressed, mean reduction in proptosis and the number of complications by intervention were extracted.

The number of reviewers who undertook data extraction was not stated.

Evidence tables summarised interventions used, outcomes measured and patient characteristics for each eligible study. Weighted mean reduction in proptosis (method of weighting unstated) were calculated for each class of intervention with standard deviations and complication rate.

Fifty-six studies of 2,315 patients and 4,176 orbits decompressed (setting unknown) were identified.

Fifteen broad surgical techniques were identified. Decompression by combined transpalpebral-endoscopic technique resulted in the largest average reduction in postoperative proptosis (6mm) and lateral canthotomy and transpalpebral techniques resulted in the smallest average reduction (2.27mm). The largest improvement in visual acuity was after coronal approach orbital decompression (magnitude unstated). Weighted average for all techniques was 0.16 (SD 0.03). The overall complication rate was 9.3%. The highest complication rate was associated with endoscopic and lateral canthotomy (20%).

No single method of surgical decompression in patients with dysthyroid orbitopathy achieved consistently good outcomes and low complication rates. The reporting of outcomes should conform to a minimum data set.

The authors addressed a clear research question supported by broad but repeatable inclusion criteria. Several sources were searched. Language restrictions applied. Appropriate methods were used to reduce error and bias during study selection; no methods used to minimise bias during data extraction were reported. The internal validity of individual studies was not assessed with consequent potential for quality biases. Weighted means were presented for reduction in postoperative proptosis and improvement in visual acuity, but the methods of derivation were unstated. The reasons for not employing meta-analytical methods were unstated and may have resulted in confounding.

The author’s conclusions appeared appropriately cautious, but no data was presented regarding heterogeneity across studies and so it was not possible to comment definitively on the veracity of the conclusions.

Practice: The authors did not state any implications for practice

Research: The authors stated that larger cohorts recruited over long time periods and a minimum data set for outcome reporting were required to facilitate future meta-analysis.

Not stated.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.