Endoscopic optic nerve decompression for nontraumatic optic neuropathy

OBJECTIVE: To determine the efficacy of endoscopic optic nerve decompression for the treatment of patients with nontraumatic optic neuropathy. DESIGN: Retrospective case series. SETTING: Academic medical center. PATIENTS: Ten optic nerve decompressions were performed on 7 patients with nontraumatic optic neuropathy caused by various pathologic entities, including meningioma, lymphangioma, fibro-osseous lesions (fibrous dysplasia and osteoma), mucopyocele, and Graves orbitopathy. INTERVENTIONS: Endoscopic instrumentation was used in a transnasal fashion to decompress the optic nerve. MAIN OUTCOME MEASURES: Visual acuity and complication rates. RESULTS: Mean visual acuity improved from 20/300 preoperatively to 20/30 after surgery. Visual acuity improved by at least 2 lines on the Snellen chart following 7 of the 10 decompressions. Median operative time was 133 minutes, and median length of stay was less than 24 hours. Complications were limited to postoperative hyponatremia and corneal abrasions, both of which resolved with conservative therapy. Mean follow-up time was 6.1 months. CONCLUSION: Endoscopic optic nerve decompression appears to be an effective treatment for restoring visual acuity in select patients who present with compressive optic neuropathy.     

鼻内镜视神经减压术治疗外伤性视神经病与VEP的诊断价值

目的探索鼻内镜下视神经减压术的疗效及影响疗效的相关因素。方法外伤性视神经病37例,在外伤后3～30d内行鼻内镜下视神经减压术。13例病人术前和术后行FVEP检查。结果37例病人中21例术后视力获得改善,有效率为56.8%。13例术前和术后行FVEP监测中,能引出P100波的患眼术后疗效好于无P100波者(P<0.005)。结论外伤性视神经病应积极采用视神经减压术,手术后疗效与视神经的损伤程度密切相关,似并不完全取决于伤后时间。术前FVEP检测情况对预测预后有一定的帮助。     

鼻内镜下视神经减压术治疗外伤性视力完全丧失的预后相关因素分析

目的探讨鼻内镜下视神经减压术对外伤性视力完全丧失的疗效,并评估其预后相关因素。方法回顾性分析85例外伤性视力完全丧失患者的临床资料,通过单因素分析和Logistic回归分析来评估其潜在的预后相关因素。结果鼻内镜下视神经减压术后,患者总体视力提高44．7％（38J85）。单因素分析显示：筛窦和（或）蝶窦内积血是视力改善的负性因素。而Logistic回归分析显示：外伤到手术的时间超过3d、筛窦和（或）蝶窦内积血与外伤性视力丧失的预后呈负性相关。结论筛窦和（或）蝶窦内积血、外伤到手术的时间超过3d是外伤性视力丧失视力恢复的危险因素。视力完全丧失的患者伤后3d内如能实施手术,视力可能得以较好改善。     

鼻内镜下视神经减压术治疗外伤性视神经损伤临床观察

目的探讨鼻内镜下视神经减压术治疗外伤性视神经损伤的临床疗效,并分析其手术预后的相关因素。方法回顾性分析广东省人民医院耳鼻咽喉科2004年11月～2016年3月期收治且具有完整随访资料的109例（110眼）外伤性视神经损伤患者的临床资料,其中男95例,女14例;年龄6~65岁,平均年龄27岁。所有患者均接受鼻内镜视神经减压术,评估手术的临床疗效及预后相关因素。采用SPSS 22.0软件进行统计学分析。结果所有患者均随访3个月以上,手术的总体视力改善率为55.5%（61/110）,其中有效率21.8%（24／110）,显效率33.7%（37／110）;术前视力有光感者视力改善率达100%（24/24）,无光感者为44.2%（38/86）;没有病例术后视力较术前变差。手术时间距离受伤时间＜3 d者视力改善率为59.5%（22/37）,3~7 d为53.3%（32/60）,＞7 d为53.9%(7/13);术中切开视神经鞘膜者视力改善率为50.0%（4/8）,不切开者为55.9%（57/102）。单因素分析结果显示,术前视力与患者的手术预后呈显著的正相关（P=0.001）。而Logistic回归分析显示,年龄、性别、术前视力、外伤到手术间隔的时间以及术中是否行视神经鞘膜切开均不是影响患者手术预后的显著因素。结论鼻内镜下视神经减压术是治疗外伤性视神经损伤的有效手段,且外伤至手术的时间及术中是否行鞘膜切开与手术预后无显著相关。     

Salvage optic nerve decompression for traumatic blindness under nasal endoscopy: risk and benefit analysis

Objectives: Transnasal endoscopic optic nerve decompression was recommended to treat traumatic optic neuropathy as an effectively adjunctive procedure. The aim of this study was to assess the risks and benefits of salvage surgical decompression for complete vision loss (no light detection) after failure of mega‐dose steroid therapy. Design: Retrospective study. Setting: Two hospitals in Guangzhou and Nanjing, China. Participants: Forty‐two patients of traumatic optic neuropathy with complete vision loss and failed to improve after steroid therapy for at least 3 days. Main outcome measures: All patients were treated by transnasal endoscopic optic nerve decompression and received follow‐up for at least 6 month. Vision improvement and complications were evaluated. Results: Transnasal endoscopic optic nerve decompression was performed successfully in 40 patients and was incomplete in two patients due to bleeding. Vision improved in four of 42 patients (9.5%) of traumatic optic neuropathy with complete vision loss and failed steroid therapy. Complications and sequelae included severe bleeding (two cases), cerebrospinal fluid rhinorrhea (one case), nasal polyps (seven cases), chronic sinusitis (four cases) and nasal synechia (17 cases). Conclusion: Transnasal endoscopic optic nerve decompression was recommended as a minimally invasive, safe procedure, but complications and sequelae of the surgery should not be neglected. Based on the risk and benefit analysis, we conclude that the very poor surgical outcomes of this series do not support endoscopic optic nerve decompression for traumatic blindness.     

外伤性视神经损伤经鼻内镜视神经减压手术时期选择及疗效观察

目的 观察鼻内镜下视神经减压术治疗外伤性视神经损伤的疗效和最佳手术时间.方法 对1998年4月至2007年3月90例头部和(或)颌面外伤后发生93眼外伤性视神经损伤的患者进行回顾性分析.所有患者接受鼻内镜视神经减压术前对药物治疗均无反应或效果不佳.受伤至手术时间1～97 d,中位手术时间5.5 d.术前无视力71眼,有视力22眼(1眼光感,5眼眼前手动,13眼眼前指数,1眼视力0.04,2眼视力0.1).随访时间6 d～2年,中位随访时间8 d.结果 视神经减压术后35例(36眼,38.7%)视力有改善,53例(55眼,59.1%)无变化,2例(2眼,2.2%)视力下降.术前有视力的患者中,视力改善者达68.2%(15/22眼),外伤后立即或逐渐失明的患者中视力改善分别只有22.9%(8/35眼,仅2眼视力恢复到大于0.02)和36.1%(13/36眼,5眼视力恢复到大于0.02),术前有视力和无视力两组视力术后恢复差异非常显著(X2=11.864,P<0.01).无视力的患者中,伤后3 d内手术视力改善为41.2%(7/17眼),3 d后手术视力改善下降到25.9%(14/54眼),但两者之间差异无统计学意义(X2=1.46,P>0.05).不同受伤部位比较,视神经管内外侧壁同时骨折手术效果最好(55.6%,10/18眼),其次为内侧壁骨折(45.7%,21/46眼),最差为没有骨折(20%,4/20眼)和单纯外侧壁骨折患者(11.1%,1/9眼).结论 为了挽救患者视力,应尽早行鼻内镜视神经减压手术,即使伤后立即丧失视力也不要放弃手术治疗.但手术后所获得的满意的视力恢复仍然需要进一步研究.     

鼻内镜下视神经减压术治疗外伤性视神经病72例

目的 探讨视神经减压术治疗外伤性视神经病的疗效。方法 对大剂量糖皮质激素冲击治疗无效的外伤性视神经病患者72例（73眼），采用鼻内镜下视神经减压术治疗。外伤至手术时间1～57d，其中≤3d15例，4—7d37例，8—10d9例，11—15d5例，16～30d5例，〉30d1例。术前视力：光感以上18眼；无光感55眼。结果 术后随访3个月-5年。73眼中46眼视力有不同程度的提高，总有效率63．01％。原无光感的55眼中，31眼视力有提高，有效率56．36％。有光感以上视力的18眼中，15眼视力有提高，有效率83．33％。术后全部患者术腔上皮化，术中无并发症发生。结论 经鼻内镜筛蝶窦入路视神经减压术进路简捷，损伤较小、疗效确切，且不遗留面部瘢痕，容易为患者所接受。对伤后时间较长、大剂量激素治疗无效、视力损伤严重的患者，手术仍有挽救视力的可能。     

鼻内镜下视神经减压治疗外伤性视神经病

目的 探讨鼻内镜下视神经减压治疗外伤性视神经病的疗效。方法 对外伤性视神经病患者应用大剂量皮质类固醇治疗,无效者15例行鼻内镜下视神经减压术。术前视力无光感者5例,光感者4例,眼前手动者3例,眼前数指者2例,视力0.1者1例。受伤至术前不足7d 4例,超过7d 11例。结果 术后随访3个月至4年, 9例视力有不同程度提高,总有效率为60%,术前无光感眼有效率为20%,有光感以上视力者术后有效率为80%。结论 鼻内镜视神经减压对外伤性视神经管内段神经病疗效确切、较其他径路创伤较小,尽管超过创伤7d,仍然是一种良好方法。     

经鼻内镜视神经减压术治疗外伤性视神经病

目的 探讨经鼻内镜视神经减压术治疗外伤性视神经病(TON)的临床疗效及相关预后因素.方法 回顾性分析深圳市龙岗区耳鼻咽喉医院2015-2018年21例TON患者经过大剂量激素冲击治疗无效后经鼻内镜行视神经减压术,术后以提高患者视力级别作为判断临床疗效的标准.结果 术后常规予抗生素及激素、改善循环、营养神经等药物治疗,所...     

Endoscopic and transconjunctival orbital decompression for thyroid-related orbital apex compression

OBJECTIVE: To evaluate the efficacy and safety of a combined endoscopic and transconjunctival orbital decompression in patients with thyroid-related orbitopathy with orbital apex compression. STUDY DESIGN: Retrospective review. METHODS: A sequential series of patients with thyroid-related orbitopathy presenting with orbital apex compressive myopathy with and without optic neuropathy who were undergoing combined endoscopic and transconjunctival decompression by the same surgeons from 1992 to 2001 was reviewed. Patients were regularly evaluated preoperatively and postoperatively over a 3- to 55-month period to record the effects of this approach on visual acuity, Hertel exophthalmometry, and diplopia. Complications and secondary ophthalmological procedures were reviewed. RESULTS: Between 1992 and 2001, 72 combined endoscopic and transconjunctival decompressions were performed on 41 patients with orbital apex compression. Visual acuity improved in 89.3% of the patients with compressive optic neuropathy (P <.0005) and in 34.1% of those without neuropathy. Proptosis was reduced by 3.65 mm, on average. There was one case of transient intraoperative cerebrospinal fluid extravasation at the site of the optic nerve decompression, and one patient developed epistaxis. CONCLUSIONS: The study supports the treatment of thyroid-related orbital apex compression with and without compressive optic neuropathy by a combined transconjunctival and endoscopic approach. This approach offers short hospital stays, excellent visual recovery, and minimal complications in patients with thyroid-related orbital apex compressive myopathy and related compressive optic neuropathy. The beneficial effects observed in the patients with visual loss continued to improve over time and were significant (P <.001).     

内镜下治疗鼻源性视觉障碍的临床研究

目的 探讨鼻源性视觉障碍性疾病的诊断与治疗模式.方法 回顾性分析23例(25眼)资料完整的鼻眼相关视功能障碍病例,23例均行内镜下鼻腔鼻窦探查+鼻窦开放术,其中9例行视神经管减压术.结果 双侧全组鼻窦炎4例,单侧后组筛窦、蝶窦炎6例,额窦、筛窦炎1例,孤立性蝶窦炎5例,单侧后组筛窦、蝶窦真菌病5例,单侧蝶窦、筛囊肿或脓囊肿2例,均经术后病理证实.术前视功能:2例(2眼)无光感;6例(7眼)眼前手动;7例(7眼)眼前指数(＜ 20 cm);8例(9眼)有不同程度视力下降.1例次(1眼)眼球突出、直接和间接瞳孔对光反射消失;3例次(3眼)复视;2例次(2眼)外展麻痹;3例次(3眼)视野缺损(1眼中央性,2眼颞侧);1例次(1眼)上睑下垂.全部病例术后鼻窦术腔上皮化.术后视功能:2眼无改善;10眼恢复到发病前水平;13眼由术前眼前手动、指数改善到眼前指数(30～60 cm).其他眼部症状消失.结论鼻源性视觉障碍患者出现视力障碍时,若药物保守治疗无效应及早行鼻内镜下鼻腔鼻窦探查术;对严重视力障碍、视力急剧下降患者及早实施视神经减压手术,可以有效改善患者的视功能.     

Delayed optic nerve decompression for indirect optic nerve injury

OBJECTIVE: To test the efficacy of delayed optic nerve decompression in traumatic optic nerve injury. STUDY DESIGN: Critical analysis of Proforma-based, prospectively accrued data of all cases with injury to surgery interval of greater than 2 weeks. METHODS: Thirty-five cases with a median injury to surgery interval of 56 days (range, 16-374 d). Surgical decompression was undertaken only in cases that continued to have poor vision after treatment with steroids in conventional doses (1 mg/kg prednisolone). Pre- and postoperative visual acuity measurements were converted to the logMAR scale of visual acuity and the percentage of visual improvement was calculated. RESULTS: Surgery was universally unrewarding in all 9 cases with persistent and complete blindness of greater than 2 weeks and no response to steroid therapy. Of the cases with some residual vision, 20 of 26 cases improved (mean percentage improvement, 41.0 +/- 5.7%). Cases were categorized on the basis of the injury to surgery interval into groups of 2 weeks to 2 months, 2 months to 4 months, and greater than 4 months. No significant difference was demonstrated in the probability or quantum of improvement in these groups (P =.97). CONCLUSIONS: Optic nerve decompression remains useful as a salvage procedure for conventional dose steroid failed cases of traumatic optic neuropathy. In cases that are not completely blind, vision can be improved even when surgery is undertaken a few months after the injury.     

鼻内镜下视神经管减压术治疗外伤性视力障碍14例报告

目的：探讨视神经管减压术治疗外伤性视力障碍的有效方法。方法：采用鼻内镜下视神经减压术治疗外伤性视力障碍患者14例。结果：随访3-18个月，其中8例有不同程度视力改善，6例无效。术后全部患者术腔上皮化，无并发症发生。结论：经鼻内镜筛蝶窦入路视神经减压术损伤较小，疗效确切，且不遗留面部瘢痕，容易为患者所接受。对伤后数天至1个月、大剂量激素治疗无效、视力损伤严重的患者，手术仍有可能挽救视力。     

经鼻内镜下视神经减压术39例报告

目的：探讨经鼻内镜下视神经减压术治疗管段视神经损伤的可行性,技巧及优点。方法：回顾性分析39例视神经损伤的病例,伤后2-18d行手术治疗,采用鼻内镜下经鼻视神经减压术,经筛窦或蝶窦自然开口进入蝶窦,寻找视神经管及骨折部位,去除骨管周壁的1.3-1.2,切开视神经鞘膜,明胶海绵及凡士林纱条填塞鼻腔,术后给予药物,高压氧治疗。结果：随访至少3个月,39例患者（40眼）中,5例失访,术后视力发送的总效率为52.5%(21-40）。受伤至手术的时间间隔2-7d手术者,术后视力改善的有效率为58.6%(17-29);7-18d手术者,术后视力改善的有效率为36.1%(4-11)。视力恢复期约2个月。结论：经鼻内镜下视神经减压术具有视野清晰,无需开颅,侵袭性小,头面部不遗留瘢痕,并发症少等优点。手术恢复的程度与视神经损伤的程度,手术时间的选择及手术技巧等因素相关。     

上颌窦筛窦径路视神经管减压术的临床探讨

目的：抢救视神经因外伤、炎症所致的视力障碍。方法：经上唇龈扩大柯陆氏切口，上颌窦、筛窦径路显微镜下持视神经管减压术１２例。结果：术后视力不同程序恢复５例，７例地效。结论：一旦视神经管骨折，视力呈进行性减退，或失去光感经激素、脱水消炎等治疗无效，应尽快行减压术。     

手术联合药物治疗外伤性视神经病的疗效分析

目的 评价手术联合药物治疗外伤性视神经病(traumatic optic neuropathy,TON)的疗效,分析影响临床疗效的因素.方法 对69例(70眼)确诊为TON并行鼻内镜下视神经管减压术联合药物治疗患者的临床资料作回顾分析.将入院时视力分为无光感、光感、眼前手动、眼前指数和能见标准视力表(0.02以上)5个级别,分别计为Ⅰ～Ⅴ级.入院视力Ⅰ级(无光感)者40眼,18眼因CT证实严重视神经管骨折,急诊行鼻内镜下视神经管减压术;22眼入院后先行糖皮质激素冲击治疗后再行手术治疗.入院视力I级以上者30眼,CT显示视神经管骨折的16眼行急诊手术;14眼行糖皮质激素冲击治疗3 d后行手术治疗.随访3～12个月,观察视力恢复情况.结果 入院视力有光感者疗效显著优于入院视力无光感者(90.0%比27.5%),两组疗效相比差异有统计学意义(χ2=26.98,P<0.001).入院视力Ⅰ级患眼,糖皮质激素冲击治疗后视力提高者手术疗效(80.0%)优于无改变者(5.9%),两组疗效相比差异有统计学意义(χ2=12.09,P<0.001).结论 对于无光感的患者,经药物冲击治疗后视力仍无改善者,手术疗效较差;治疗前视力是影响疗效的主要因素.影像学检查有无视神经管骨折,不应作为是否手术的决定因素.     

Endoscopic Optic Nerve Decompression: The Graz Experience

Recommendations for management of traumatic injuries to the optic nerve in the literature include expectant management, medical therapy, surgical treatment, and medical therapy combined with surgical decompression. Traditional surgical approaches to optic nerve decompression (OND) are a neurosurgical or craniotomy approach, extranasal transethmoidal approach, transorbital approach, transantral approach, and intranasal microscopic approach. Recent advances in instrumentation and surgical techniques have made an endoscopic approach to OND possible. Since 1991 endonasal endoscopic decompression of the optic nerve has been the surgical approach of choice in patients requiring OND in the authors' hospital. The endoscopic method offers many advantages over the traditional approaches. Decreased morbidity, preservation of olfaction, rapid recovery time, more acceptable cosmetic results with no external scars, no risk of injury to the developing teeth in children, and less operative stress in a patient who may have multisystem trauma are only some of the benefits associated with the endoscopic OND. The authors' technique of endonasal endoscopic approach to OND, medical management, and indications for surgery and the results in 22 patients undergoing this procedure are discussed.     

视神经减压术中蝶窦外侧壁的结构辨认和保护

目的探讨鼻内镜下视神经减压术中如何准确找到和开放视神经管,避免毗邻重要结构损伤,并介绍术中大动脉出血的紧急处理。方法确诊为外伤性视神经病的患者3 0例,术前明确视神经、颈内动脉、眼动脉的位置和损伤情况,定位彼此间的解剖关系。术中以术前的影像学资料为依据初步定位视神经的位置,采取直接开放视神经管或沿眶尖向后逐渐开放视神经管的方式减压视神经,同时注意毗邻解剖结构的保护。结果 30例均准确定位视神经管和视神经;28例顺利完成视神经减压;2例眼动脉假性动脉瘤出血,经及时窦腔填塞止血,终止视神经减压手术;无手术所致的视神经、颈内动脉、眼动脉和海绵窦损伤等严重并发症。结论以影像学资料为依据选择恰当的方法开放视神经管;注意蝶窦外侧壁结构的保护,并掌握紧急处理和预防颈内动脉和眼动脉出血的方法;是防止严重并发症和保证手术顺利完成的关键。     

鼻内镜鼻窦手术眼部并发症及其处理对策

目的 探讨鼻内镜鼻窦手术的眼部并发症可能的原因及处理经验,以期引起鼻内镜外科医生的重视.方法 收集作者收治的具有比较典型特征的鼻窦手术眼部并发症者22例8类.损伤类型分别为:纸样板损伤、眶内感染、额筛阻塞性囊肿、泪道损伤、眼外肌损伤、眶内出血、视神经损伤、眼底动脉栓塞等,并给予了相应处理.结果 单纯纸样板损伤9例中8例经保守治疗痊愈,眶纸样板损伤伴眶骨膜下感染1例和泪道损伤、额筛阻塞性囊肿各1例经鼻内镜手术痊愈.眼外肌损伤2例中1例经眼肌矫正术后除向健侧有轻微复视外,其他眼位无明显复视;另1例经眼肌矫正后仍有轻度复视.眶纸样板损伤致眶内出血1例痊愈,另1例眶内出血和1例眼底动脉栓塞导致的视力丧失无改善.视神经损伤6例(7侧)中1例(1侧)经视神经减压+眶尖减压视力恢复正常,另1侧及其余5例(5侧)无改善.结论 鼻内镜手术导致视神经损伤、眶内出血和眼底动脉栓塞导致的失明,治疗困难,预后极差;如果有残存视力,预后较好.     

双侧外伤性视神经损伤的经鼻内镜拯救手术

目的探讨双侧视神经损伤经鼻内镜手术治疗的必要性.方法对4例双侧外伤性视神经损伤导致完全失明的患者采用经鼻内镜视神经减压手术和综合性药物治疗,并分析其疗效.结果除1例伤后立即失明的患者外,其余伤后逐渐失明患者的视力治疗后均有不同程度的恢复.病例1伤后30 d手术,单侧视力从光感恢复至1.5;病例2伤后3 d手术,单侧视力从光感恢复至0.2;病例3伤后立即失明,双侧无光感,伤后6 d手术,双侧视力均无恢复;病例4伤后28 d手术,术前均无光感,术后左侧视力恢复至0.8,右侧恢复至0.2.结论对双侧外伤性视神经损伤导致失明的患者应积极采用手术治疗;长时间失明者仍有恢复视力的可能性;伤后视力逐渐丧失或遗留残余视力是手术治疗有效的基本依据,伤后即刻失明者,视力恢复的可能性较小.