眶尖部肿瘤的诊断与治疗

本文回顾性分析了我院诊治的眶尖部肿瘤２９例。病理检查为海绵状血管瘤１０例，神经鞘瘤８例（其中复发性神经鞘瘤３例），视神经鞘脑膜瘤７例，继发肿瘤及转移瘤３例。眶尖肿瘤主要表现早期视力障碍，轻度眼球突出，眼底视盘水肿或萎缩，早期易误诊。ＣＴ及ＭＲＩ显示眶尖部肿瘤，手术难度较大，合并症多。本文讨论了几种常见眶尖肿瘤的临床诊断特点、手术治疗原则及注意事项     

结膜入路摘除眶内海绵状血管瘤的临床分析

目的探讨结膜入路摘除眶内海绵状血管瘤的适应证选择、手术技巧及并发症处理。方法回顾性分析2004年8月至2011年11月于我院经结膜入路手术治疗的海绵状血管瘤42例(42只眼)。结果 1例改行外侧开眶,3例改前路开眶,2例未寻找到肿瘤为保存视功能放弃手术,其余均顺利切除肿瘤。除1例视力丧失外,无明显并发症。结论微创结膜入路摘除眶内海绵状血管瘤安全有效,关键在于术前对肿瘤性质、位置、粘连程度的正确判断以及术者的手术技巧和临床经验。     

经额眶入路切除眶尖肿瘤11例疗效分析

目的 探讨采用经额眶入路摘除眶尖肿瘤的疗效。方法 11例眶尖肿瘤，手术先由神经外科作经额部的4边形额肌骨瓣，然后沿前颅窝底取下眶顶骨板、切开骨膜入眶。随后由眼科医生进行眶内肿瘤摘除的操作，再由神经外科医生继续处理有颅眶沟通者的颅内部分并关闭切口。结果 11例中有9例显微镜下完整摘除肿瘤，2例部分摘除。术后视力无下降，术前9例视力下降者，术后7例有提高。眼球突出度平均降低1．5mm；眼球轻度下陷1例；术后发热1例。无1例发生与开颅有关的并发症。结论 眼科与神经外科联台行经额眶入路眶尖肿瘤摘除术，可以满意地解决眶尖肿瘤难以暴露的问题，绝大多数良性肿瘤可完整摘除甚至是在显微镜下摘除，有利于减少手术并发症的发生，疗效满意。     

眶颅沟通性肿瘤的诊断和手术治疗

目的：探讨眶颅沟通肿瘤的临床特征、种类、诊断方法及手术治疗。方法：选择60例手术病理或随访结果证实的眶颅沟通肿瘤患者，所有患者均行CT扫描，54例行MRI扫描，其中增强扫描42例。20例行视神经管X光像。经翼点入路切除肿瘤12例，经额入路切除肿瘤21例。结果：最常见的阳性体征是眼球突出、眶压升高和视力下降等，最常见的症状是头痛。较多见的眶颅沟通肿瘤是脑膜瘤、骨纤维异常增生症和转移癌。眶颅沟通肿瘤的CT、MRI扫描及视神经孔X光像有一定影像学特征。眶颅沟通的途径包括视神经管、眶上裂和眶颅交界骨壁。全切肿瘤32例，次全切肿瘤1例。结论：掌握各种眶颅沟通肿瘤的临床特征、病种分类，综合运用CT、MRI和X光等检查方法可提高诊断和鉴别诊断水平。翼点入路和经额入路是眶颅沟通肿瘤的重要手术方法。     

眶尖部气枪弹异物手术体会

眶尖部气枪弹异物能直接损伤视功能甚至失明，手术难度较大，今将我们所遇7例处理体会报告如下。临床资料本文报告7例中，男5例，女2例；年龄16～45岁；就诊时间在12小时至ZO天．术后观察5年。眶尖部气枪弹异物病例（附表）。手术方法我们多采用经内附部皮肤切口，沿眶内壁入路     

眶颅肿瘤的手术治疗

目的 探讨眶内肿瘤和眶颅沟通肿瘤的手术入路。方法 总结３年来１１例手术治疗的经验。结果 １０例肿瘤全切，１例次全切，无手术死亡。结论额下入路开颅和外侧开眶切除眶内和眶颅肿瘤是实实用的手术方式。     

不同手术入路治疗眼眶肿瘤的疗效分析

目的：分析不同手术入路治疗眼眶肿瘤的临床效果。

方法：我院眼科2012-01/2017-06收治的眼眶肿瘤患者52例56眼均行颅脑核磁共振(MRI)及眼眶计算机断层扫描(CT)明确肿瘤与周围解剖结构的关系,并行开眶手术治疗,入路方式包括经结膜入路前路开眶术、外侧开眶术、内外侧联合开眶术,统计所有患者肿瘤切除情况、视力恢复情况、术后早期并发症以及随访复发情况。

结果：本组52例患者中有7例8眼(14%)肿瘤残留,经结膜入路前路开眶术肿瘤残留率(23%)高于外侧开眶术、内外侧联合开眶术(6%、7%),差异均有统计学意义(P<0.05)。本组患者视力提高者28例30眼(54%)、无变化者18例19眼(34%)、下降者6例7眼(13%); 早期并发症发生率为23%,包括意外视力丧失2例2眼、瞳孔改变2例2眼、上睑下垂3例3眼、眼动障碍5例6眼,主要集中发生于老年患者; 三种手术入路视力恢复情况、并发症发生率(23%、19%、29%)接近,差异均无统计学意义(P>0.05)。随访期内,52例患者中有3例3眼(5%)复发,内外侧联合开眶术术后复发率(14%)明显高于经结膜入路前路开眶术、外侧开眶术(4%、0),差异均有统计学意义(P<0.05)。

结论：选择合适的手术入路可成功摘除眼眶肿瘤、改善或稳定视功能、减少手术并发症和复发情况。     

眶内异物摘出手术入路的设计

手术入路在外科手术操作中很重要。任何手术，都存在从哪里进入的问题，这关系到手术野的暴露，病灶的切除，手术顺利成功与否等问题。眼部常见的手术，已有经典的手术入路，比如眶内肿瘤手术常用于暴露眼眶的经眶上壁入路和经眶外侧壁入路。但对于一些特殊的病例，如眼眶内异物，临床上并没有固定的模式可以遵循，需要根据病情，找寻最适合的手术入路，设计切口。     

经眶顶入路摘除眶后部肿瘤(附16例报告)

摘除眶后部肿瘤的手术入路问题,在眼科手术中常有争议。本文介绍经眶顶入路切除眶后部肿瘤,不仅术野暴露清楚,且对肿瘤全切及减少术后并发症,均取得良好效果,为切除眶内后部肿瘤提供了一条可取的途径。     

眶尖减压术治疗外伤性眶尖综合征

目的 探讨眶尖减压术治疗外伤性眶尖综合征的疗效。方法 对11例外伤性眶尖综合征患者,根据眶尖区不同受损伤部位,采取不同手术入路的眶尖减压术,其中5例经额入路,6例经翼点入路。术后视力的评价标准分为5个级别：失明、光感、眼前手动、眼前数指和能见视力表符号5个级别。术后视力提高1个级别者为有效,否则为无效。并对眶上裂区神经恢复情况进行评价,有两项神经恢复为有效。结果 术前失明患者6例,3例有效(50％);残存视力患者5例,视力均有不同程度提高;眶上裂区神经均有不同程度的恢复,4例眼球突出均得到矫正。结论眶尖减压术是治疗眶尖综合征的有效方法,可同时治疗合并脑损伤的患者,术后恢复效果与损伤后手术时间、手术方法及神经损伤程度密切相关。（中华眼科杂志,2004,40：804-807)     

Treatment and long-term outcome of patients with orbital cavernomas

PURPOSE: To evaluate the long-term prognosis of visual function in patients with orbital cavernomas after conservative and surgical treatment. DESIGN: Interventional case series. METHODS: The authors describe the outcome of 20 patients with cavernous hemangiomas of the orbit treated in their departments between 1988 and 2003. This prospective study included five cases followed by clinical and radiologic observation and 15 cases of symptomatic tumors that were completely removed by means of a frontotemporal or by means of a transconjunctival approach. The clinical characteristics of orbital cavernomas were analyzed together with their appropriate treatment. Furthermore, the authors present the unusual case of a patient suffering from progressive visual deterioration from a cerebral cavernoma compressing the optic nerve. RESULTS: The follow-up period was between 3 and 10 years. All orbital cavernomas in the group of conservatively managed patients remained stable. The transconjunctival excision of a medially located lesion was uncomplicated. The frontotemporal approach was chosen for large tumors situated in the proximity of the orbital apex and was associated with a higher number of complications. A good overall outcome of visual function and patient satisfaction was achieved in 11 of 14 cases operated on by craniotomy. CONCLUSION: The combination of clinical signs and magnetic resonance imaging (MRI) is highly sensitive and specific for the diagnosis of orbital cavernomas. In the presence of visual deterioration clearly attributable to the tumor we recommend immediate surgery, while lesions producing solely exophthalmos can safely be followed by observation. The transcranial approach offers excellent exposure and a rewarding cosmetic result and may be considered for large lesions superior and medial to the optic nerve, especially if they involve the orbital apex.     

非特异性炎症致眶尖综合征临床特征分析

目的 总结眶尖非特异炎症导致眶尖综合征患者的临床特征。设计 回顾性病例系列。研究对象 2016年6月至2019年5月北京同仁医院神经眼科及北京市普仁医院眼科眼眶非特异性炎症致眶尖综合征15例（16眼）。方法 回顾患者的临床症状、体征、化验及影像学检查、激素治疗效果及病情转归。主要指标 临床表现、眼眶及头颅CT、MRI表现。结果 15例中男性8例,平均年龄（53±16）岁。14/15例单眼发病。病灶均局限于眶尖区,7例同时累及海绵窦。首先出现患侧眼眶疼痛,相继出现眶尖综合征表现。眼眶MRI均显示眶尖部条片状不规则实性病灶,呈等T1WI、等T2WI信号,均匀强化。经全身或眼球局部糖皮质激素治疗后14眼（87.5%）眼痛完全消失,13眼（81.3%）上睑下垂改善,11眼（68.8%）眼球运动及复视症状改善。3个月后复查眼眶MRI病灶均缩小。仅一半患者治疗后视力提高,其余8眼（50.0%）视力无改善。随访过程中2例（12.5%）病变复发。结论 局限于眶尖的非特异炎症可导致严重的眶尖综合征。早期无眼红肿等炎症表现,眼球突出亦不明显,表现为眶周疼痛、眼球运动障碍,继而视力进行性损伤,易被误诊。临床表现和神经影像学是诊断主要依据。糖皮质激素治疗能有效改善眼球运动障碍和疼痛,但视力恢复困难,且病变有复发可能。（眼科,2021,30： 56-61）     

Transconjunctival orbitotomy for orbital cavernous hemangiomas

BACKGROUND: Orbital cavernous hemangiomas, particularly those within the retrobulbar space, are approached by neurosurgeons as well as by ophthalmic surgeons. Several surgical techniques have been applied over the past decades. Less traumatic approaches in this functionally and cosmetically important region are desirable. We describe a transconjunctival approach in 39 patients with orbital cavernous hemangiomas. METHODS: Thirty-nine patients with orbital cavernous hemangiomas were treated with transconjunctival orbitotomy. The clinical and radiologic characteristics of orbital cavernous hemangiomas were analyzed in the course of their appropriate treatment. RESULTS: In all patients, cavernous hemangiomas were just behind the globe or were compressing it. Computed tomography and magnetic resonance imaging showed orbital cavernous hemangiomas as round, well-defined intraconal masses. In 37 cases, the tumors were removed intact, and only 1 patient suffered permanent vision loss as a result of intraoperative hemorrhage. In the other 2 cases, the tumor fragments were incompletely removed. Visual acuity increased in 6 of the 9 cases with primary visual impairment. Thirty-two patients with primary proptosis were resolved completely. Six patients with visual field defect were also improved. INTERPRETATION: Retrobulbar intraconal cavernous hemangiomas can be removed successfully through a transconjunctival approach. However, if the tumor is close to, or touching, the orbital apex, adhering tightly to retrobulbar tissue, or combined with large draining veins, operation through other approaches must be considered.     

Long-term follow-up and prognosis of orbital apex syndrome resulting from nasopharyngeal rhabdomyosarcoma

PURPOSE: Nasopharyngeal rhabdomyosarcoma may present with a variety of ophthalmic symptoms. Direct extension of the tumor into the orbital apex can lead to ophthalmoplegia and loss of vision. The prognosis for recovery of vision and ocular motility in patients with an orbital apex syndrome due to nasopharyngeal rhabdomyosarcoma is examined. DESIGN: Retrospective case series. METHODS: Six eyes from four patients with nasopharyngeal rhabdomyosarcoma who presented to the Children';s Hospital of Philadelphia with a clinical orbital apex syndrome were identified. Complete ophthalmic examination, including visual acuity and extraocular motility at the time of presentation, was reviewed. Tumor extension into the orbital apex was confirmed radiographically. Follow-up ophthalmic evaluations were reviewed for all patients with an average follow-up of 5.5 +/- 3.1 years (range 1 to 8 years). RESULTS: Six eyes of four patients had limited ocular ductions along with marked loss of vision at presentation. All patients were treated with chemotherapy and radiation, with reduction of tumor mass. Ocular motility recovered in all patients, occurring by an average of 2.2 +/- 1.8 months after initiation of therapy. Four of six eyes had little or no recovery of visual acuity detected at long-term follow-up. CONCLUSIONS: Patients with ocular motor deficits in orbital apex syndromes caused by extension of nasopharyngeal rhabdomyosarcoma have an excellent prognosis for recovery after treatment of the tumor. The long-term prognosis for visual recovery, however, is poor.     

眶尖部及视神经肿瘤的早期诊断

目的探讨眶尖部及视神经肿瘤在眼球突出前的临床表现、影像学检查特征及临床诊断要点。方法回顾性分析22例无明显眼球突出单侧眼眶肿瘤患者的病历资料,包括主要症状、首发表现、临床诊治过程及影像学检查结果。结果22例肿瘤患者中,海绵状血管瘤6例,神经鞘瘤、视神经鞘脑膜瘤、鼻窦及鼻咽腔恶性肿瘤眶内蔓延各4例,后组筛窦黏液囊肿2例,神经纤维瘤和视神经胶质瘤各1例。以视力下降为首发症状者17例,视力下降合并复视者3例。全部患者均在CT或MRI检查后确诊。肿瘤位于眶尖部或起源于视神经。结论眶尖部及视神经肿瘤的早期症状是视功能障碍,无眼球突出表现。视力呈缓慢进行性下降,按视神经炎治疗效果差。CT或MRI检查对早期诊断起重要作用。     

Decompression of benign orbital apex lesion via medial endoscopic approach

The use of endoscopic orbital and optic nerve decompression for traumatic optic neuropathy and dysthyroid orbitopathy have been well documented; however, reports on endoscopic decompression for benign orbital apex lesions are scarce. The records of two patients who underwent endoscopic decompression of the bony orbit for progressive visual loss were reviewed. Patient 1 had fibrous dysplasia and presented with headache and visual field defects. Patient 2 had sphenoid wing meningioma and multiple previous attempts of transcranial tumor resection and orbital decompression. Both had progressive visual deterioration and ultimately underwent transnasal endoscopic orbital decompression. Post-operatively, both patients had subjective and objective improvement in visual function and compressive symptoms. No complications from the endoscopic decompression were observed in both patients. Transnasal endoscopic approach may be a viable option for decompression of benign orbital apex lesions.     

Interactive image guidance for surgical localization of orbital apical tumors

The surgical management of orbital apex tumors is difficult. Intervention in this small posterior space is fraught with complications. We have used an interactive image guidance system to successfully biopsy and resect three tumors at the orbital apex without significant surgical morbidity. These three cases are presented. These interactive image guidance systems have revolutionized skull-base surgery and have a role in the surgical management of orbital apex tumors.     

Progressive visual loss and motility deficit

A 63-year-old female with known stage III, low grade non-Hodgkin's lymphoma presented with progressive visual loss in the left eye and binocular diplopia in all positions of gaze. The left globe was almost immotile. Two MRI's of the orbit were interpreted as normal. Lumbar puncture did not reveal abnormal cytology. Although orbital apex involvement is uncommon in non-Hodgkin's lymphoma, the patient's clinical findings clearly indicated a lesion in this area, which was confirmed by a third MRI. Review of one of the initial films showed evidence of orbital apex involvement. To prevent diagnostic delay and unnecessary repeat imaging, the clinical diagnosis of orbital apex syndrome should be clearly communicated to the radiologist. Prompt recognition of orbital apex syndrome may improve visual outcome.     

Endoscopic approach to orbital apex lesions

PURPOSE: To examine the role of transnasal and transantral endoscopic surgical approaches in the management of apical orbital lesions. METHODS: Retrospective case series. RESULTS: Three patients underwent combined orbital and endoscopic surgery for treatment of apical orbital lesions. In two of these patients, the orbital apex was decompressed, which resulted in visual recovery. Using endoscopic approaches to the posterior orbit and orbital apex allowed better visualization, with minimal manipulation of tissues in an area where surgical access is limited. CONCLUSIONS: Apical orbital lesion management benefits from a multidisciplinary and individualized plan. Endoscopic approaches can be used to improve visualization and access to a difficult surgical area. They also allow extra instrumentation to be used through the relatively capacious paranasal sinuses. These advantages may obviate lateral orbitotomy in some situations. Although endoscopic techniques are useful for biopsy, debulking, and removal of orbital apex lesions, they may be more difficult to apply to an intraconal lesion at the orbital apex.     

Transnasal transsphenoid approach: a minimally invasive approach for removal of cavernous haemangiomas located at inferomedial part of orbital apex

Ten patients complaining of visual impairment, proptosis or ocular pain, were selected for transnasal transsphenoid microsurgical approach to address cavernous haemangiomas located at inferomedial part of orbital apex. Via this approach, the contents of orbital apex were clearly illuminated and exposed as large as the surgical removal required. All tumours were identified under frameless image‐guided neuronavigation and removed completely without any complications and recurrence in a mean of 12.2 months follow‐up. It is concluded that a transnasal transsphenoid microsurgical approach is a minimally invasive surgery for cavernous haemangiomas located at inferomedial part of orbital apex.