In reply
Dr Frankel's excellent letter provides a valuable review of orbital decompression history, and I am grateful to him for identifying some early articles of which I had not been aware. In the absence of proof, Dr Frankel is correct in questioning the decompressive value of the lacrimal keyhole. I am not sure if removal of bone in the lacrimal gland fossa actually contributes to orbital decompression. In part, this bone is sculpted to achieve visualization of the deeper structures without having to actually take off the rim. Still, orbits of patients with Graves disease are often under considerable pressure, and at least during surgery, the lacrimal gland and associated tissues readily prolapse into the new bony space. My sense is that allowing the lacrimal gland to move upward and outward does provide some decompressive effect.