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The transcranial approach to the orbit requires specialized knowledge, skill, and instrumentation. It can be performed by neurosurgeons but is commonly approached collaboratively, with an orbital, skull base, and/or craniofacial plastic surgeon joining the neurosurgical team to provide specialized skills. The role of the ophthalmic plastic surgeon, as an orbital specialist, includes preoperative evaluation and planning, intraoperative anatomic expertise, and postoperative care.

Surgical management of thyroid eye disease (TED) has two general aims: (1) relieve symptoms of orbital congestion and fibrosis, including possibly compressive optic neuropathy, and (2) reconstruct the periocular region to reduce deformity and renormalize appearance. Surgical management follows a sequence that is tailored to individual patient needs. The signs and symptoms of TED that can be addressed surgically include proptosis, orbital pressure/pain, orbital inflammatory signs, diplopia secondary to restrictive strabismus, ocular surface exposure secondary to lagophthalmos, and eyelid retraction. Because orbital decompression surgery can improve lagophthalmos and eyelid retraction, and can affect strabismus (positively or negatively), these issues are traditionally addressed sequentially by orbital decompression first, followed by strabismus surgery, and finally eyelid retraction repair, as needed. In this chapter, we focus primarily on orbital decompression surgery and eyelid surgery, although key aspects of strabismus surgery are also discussed.

Thyroid eye disease (TED) is caused by an inflammatory process involving the orbit and periorbital tissues in the setting of autoimmune thyroiditis. TED has been shown not only to impact visual and social functioning but also to reduce patients’ quality of life. Thyroid dysfunction in TED most frequently involves hyperthyroidism secondary to Graves’ disease (GD); hypothyroidism secondary to Hashimoto’s thyroiditis, or subclinical inflammation, are involved less commonly. Approximately 25–50% of patients with GD will develop clinically apparent TED some time during their lifetime. Sight-threatening disease is infrequent and occurs in approximately 3–5% of patients. In contrast, subclinical manifestations, including radiographic evidence of enlargement of extraocular muscles, may be present in a larger subset of patients.

Stereotaxy involves the use of computerized technology to identify a point in three dimensions using a Cartesian coordinate system, which can be used for preoperative surgical planning and intraoperative computer-assisted surgical navigation. Stereotactic technology allows for the visualization of surgical anatomy and instrument placement intraoperatively in real-time on preoperatively acquired images, typically computed tomography (CT), magnetic resonance imaging (MRI), or CT-MRI fusion studies. Image-guided surgery has modernized a variety of surgical interventions, including radiosurgery, biopsy, implantation, resection, stimulation, and reconstruction. Although neurosurgery is the field that most frequently utilizes stereotaxy, skull base surgery, otolaryngology, oral and maxillofacial surgery (OMFS), orthopedic surgery, and other medical specialties have also appropriated image-guided surgery into their armamentarium, with notable improvements in patient outcomes. Importantly, the use of stereotactic navigation has been extended to orbital surgery by neurosurgeons, skull base surgeons, and OMF surgeons – a natural extension of this useful surgical tool.