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。     

Imaging characteristics and surgical management of orbital neurilemmomas

AIM: To review imaging characteristics and surgical outcomes of orbital neurilemmoma. METHODS: Retrospective review of 21 patients with orbital neurilemmoma managed at the Zhongshan Ophthalmic Center of Sun Yat-sen University from June 2005 to December 2016. All patients underwent surgical excision following preoperative imaging including ultrasonography, computed tomography (CT) and magnetic resonance imaging (MRI). RESULTS: Among these patients, 11 were male and 10 were female, with age ranging from 12 to 75y (average, 40.3y). Ultrasound of the orbit showed a roundish well-demarcated orbital mass with low or middle internal reflectivity in each case. Dark inner liquid fields were detected in 28.6% of these cases. Doppler ultrasound demonstrated blood flow signals in these masses. CT showed that the tumors were either homogeneous or heterogeneous. MRI of T1WI revealed isointense or hypointense tumors, while the T2WI indicated heterogeneous hyperintense lesions. Gd contrast MRI demonstrated heterogenous or homogeneous enhancement initiating from the wide area of the lesion. Six patients underwent lateral orbitotomy and 15 anterior orbitotomy. All tumors were completely removed. After a mean follow-up of 1.8y, 3 patients experienced reduced vision while the remaining 10 patients showed improved vision after surgery. One patient experienced a mild limitation of upward motility. No recurrence occurred. CONCLUSION: Orbital neurilemmoma is a relatively rare, benign orbital tumor. Effective diagnosis requires a combination of ultrasonography, CT and/or MRI. These imaging techniques are also vital to differentiate neurilemmomas from other orbital masses like that of cavernous hemangiomas and meningiomas. Successful treatment requires complete resection of the neurilemmomas as performed either by lateral or anterior orbitotomy. Recurrence is rare after complete removal.     

眼眶手术入路的选择(附90例报告)

目的：探讨眼眶手术常用入路的适应证及手术技巧。方法：武警总医院眼科自１９９９年７月至２０００年４月共做各种眼眶手术９０例（９２次）。结果：前路开眶２７例（２９次）,外侧开眶３０例,结膜入路２６例,内侧开眶３例,眶内容摘除术４例,结论：眼眶手术入路选择应根据病变性质、位置、范围和术者熟练程度而定,尽可能采取术野暴露清楚。损伤小,易于切除病变和外观良好的手术入路。     

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.     

眼眶海绵状血管瘤的手术入路选择

目的 探讨眼眶海绵状血管瘤经不同入路手术摘除的效果及其与影像学定位的关系.方法 回顾性病例研究.分析164例经手术摘除的眼眶海绵状血管瘤患者资料,并对这些患者的手术入路、影像学特征、手术效果及其选择标准进行总结.结果 经结膜入路者101例(占61.6％),位于肌锥内间隙,边界清楚且无明显黏连.经皮肤入路前路开眶者25例(占15.2％),位于肌锥外间隙,位置浅在.外侧开眶者32例(占19.5％),位于肌锥内间隙,均有较多黏连.内外侧联合开眶者5例(占3.0％),位于肌锥内间隙,形态不规则或者有较多黏连.内侧开眶者1例(占0.6％)、位于内直肌内侧.156例患者肿瘤完整摘除,仅有2例视力丧失.另8例患者患者大部分切除.结论 眼眶海绵状血管瘤可以通过选择合适的手术入路成功摘除.眼眶手术入路选择应根据病变性质、位置、范围而定,尽可能采取术野暴露清楚,损伤小、易于切除病变和外观良好的手术入路.     

A new surgical technique for excision of orbital cavernous hemangioma: a 15-year experience

Purpose: To present a new surgical technique for excision of orbital cavernous hemangiomas (CHs).

Methods: This retrospective case series study included patients with orbital CH who were operated from 2001 to 2016 at our referral center. Epidemiologic data, symptoms, signs, and images were reviewed from patients’ files with at least one year of follow-up. Surgical results and complications were documented. We used the “index finger dissection” technique without grasping the tumor for release of adhesions and its removal.

Results: We included 60 patients with orbital CH consisting of 36 (60%) female and 24 (40%) male patients with mean age of 40 ± 12.1 (range 9–66) years.

The main complaint was proptosis with average size of 5.3 ± 2 millimeters. The surgical approach was lateral orbitotomy in 49 (81.7%) patients, medial transcutaneous in seven (11.7%) patients, inferior transconjunctival in three (5%) patients, and simultaneous lateral and medial orbitotomy in one (1.6%) patient. All tumors were removed intact; complications included ptosis in one subject, lower lid retraction in one case, and diplopia in two patients, all of which improved before 2 months. No optic nerve damage occurred.

Conclusion: The “index finger dissection” technique without grasping the tumor for excision of orbital CH, via any external approach to the tumor, is a safe technique with minimal complications.     

不同手术入路摘除眼眶内海绵状血管瘤23例分析

目的:探讨眼眶海绵状血管瘤的临床特点、术前定性诊断与手术进路的适应证选择、手术方法及技巧。方法:回顾性分析2002-03/2006-03荆州市中心医院眼科手术治疗的海绵状血管瘤23例,其中,男10例,女13例;右眼9例,左眼14例;年龄18～63(平均41.2)岁;以渐进性眼球突出和视力下降为主要临床表现。10例采用前路结膜切口开眶入路,6例采用前路皮肤切口开眶入路,7例采用外侧开眶入路。结果:96%(22/23)根据超声波和CT可作出术前准确诊断。70%(16/23)采用前路开眶,30%(7/23)采用外侧开眶顺利摘除肿物。结论:眼眶海绵状血管瘤术前基本上可作出诊断,安全、有效地摘除海绵状血管瘤选择手术进路很重要,关键在于术前对肿瘤性质、位置、粘连程度的正确判断和手术操作的技巧,大部分的病例不需外侧开眶即可顺利摘除肿物。     

Surgical outcomes of transconjunctival anterior orbitotomy for intraconal orbital cavernous hemangioma

Purpose

To describe surgical outcomes for transconjunctival anterior orbitotomy for intraconal cavernous hemangiomas.

Methods

The medical records of 9 consecutive patients with intraconal cavernous hemangiomas who underwent surgical removal by transconjunctival anterior orbitotomy were retrospectively reviewed. The conjunctiva was incised and retracted with a traction suture. For large tumors, a rectus muscle was temporarily disinserted. Tenon''s capsule was separated and the tumor was removed with a cryoprobe or clamp. Surgical outcomes, positions of the tumors, methods of approach, and intra- and post-operative complications were evaluated.

Results

The mean follow-up period was 33 ± 6.8 months. No bony orbitotomy was used in this technique and the cosmetic results were very satisfactory. All tumors were removed intact. In 4 patients, tumors were extirpated with the aid of a cryoprobe. No patients had residual proptosis or limitation of ocular movement. No signs of recurrence were noted in any cases at 33 months follow-up. No serious or permanent complications were observed during or after the operation.

Conclusions

Transconjunctival anterior orbitotomy is an important surgical procedure in the treatment of intraconal cavernous hemangiomas. It can produce an excellent result, even if the posterior border of the tumor abuts the orbital apex.     

10例眼眶肿瘤手术临床分析

目的分析原发性眼眶肿瘤的组织来源、手术进路及手术效果。方法回顾性分析5年开眶手术治疗的眼眶肿瘤101例。结果前十位的眼眶肿瘤分别是:海绵状血管瘤22例(21．78％),静脉性血管瘤10例(9．9％),(表)皮样囊肿泪腺10例(9．9％),泪腺混合瘤8例(7．92％),炎性假瘤7例(6．93％),脑膜瘤6例(5．94％),腺样囊性癌5例(4．95％),淋巴瘤4例(3．96％),肉瘤3例(2．97％),神经鞘瘤2例(1．98％)。手术方法包括前路入眶68例,外侧开眶27例,眶内容6例,术后复发4例。结论开眶手术的术式选择与肿瘤的性质、位置、粘连情况、病变范围密切相关。术前对肿瘤的性质、位置、粘连程度的正确判断和手术操作技巧可减少术后复发等并发症。术后复发病例主要为脑膜瘤及泪腺肿瘤。     

Myoepithelioma of the Orbital Apex and Middle Cranial Fossa: Case Report and Review of the Literature

Myoepitheliomas are rare tumours that originate from glandular tissues such as the parotid or salivary glands, and less commonly from soft tissues of the head, neck, and other parts of the body. Intraorbital myoepitheliomas generally arise from the lacrimal gland. Intracranial myoepitheliomas are rare. We report a myoepithelioma of the orbital apex that did not originate from the lacrimal gland. It extended to the middle cranial fossa from the orbital apex and involved the dura and adjacent bone. A diagnostic biopsy via a lateral orbitotomy preceded resection. We review the natural course and histopathology of myoepithelial neoplasms, the surgical nuances of approaching an orbital apex tumour with maximal functional preservation, and the optimal management practices of these rare lesions.     

眼眶肿瘤的手术治疗探讨

目的 探讨眼眶肿瘤的种类、手术进路、治疗效果及并发症.方法 对我院2004～2005年收治的眼眶肿瘤45例（45眼）的临床表现、影像检查和治疗方法进行分析.结果 45例眼眶肿瘤中囊肿12例,海绵状血管瘤10例,静脉性血管瘤6例,泪腺多形性腺瘤5例,神经鞘瘤、非霍奇金淋巴瘤各3例,泪腺腺样囊性癌2例.视神经胶质瘤、视神经鞘脑膜瘤、神经纤维瘤及眼眶骨瘤各1例.45例均进行手术摘除,其中前路开眶32例,外侧开眶9例,经筛窦内侧开眶2例,外侧结合内侧开眶1例,经颅开眶1例.术后6个月复查上睑下垂2例,瞳孔改变3例,眼球运动受限2例.结论 眼眶肿瘤的临床表现具有多样性;大多因眼球突出而就诊;影像学检查显示多种形状的占位性病变,治疗方法以手术为主,注意手术技巧和术式的选择可以防止复发和出现并发症.     

Vertical lid split orbitotomy revisited

PURPOSE: To report the results of anterior orbitotomy through a vertical transmarginal upper eyelid incision for gaining access to superonasal intraorbital lesions. METHODS: Retrospective case series of 13 patients presenting with superonasal intraorbital lesions. RESULTS: Vertical transmarginal upper eyelid incision allowed biopsy or removal of orbital lesions in all cases with satisfactory postoperative cosmesis and function. CONCLUSION: The vertical lid split orbitotomy, initially described for anterior orbital lesions, also is useful for exposure and removal of deeper intraconal orbital masses.     

眼眶肿瘤外侧开眶术围手术期护理的探讨

目的　探讨眼眶肿瘤外侧开眶术围手术期护理及心理护理的方法。方法　术前进行详细的生理、心理评估,进行积极术前准备,使患者身心处于最佳状态,术后密切观察伤口和视力情况,采取半卧位以及视力监视等措施,防止眶内血肿和视力丧失,做好出院指导。结果　70例患者均无感染、眼眶内血肿或视力丧失等并发症发生,平均住院8.2天,均痊愈出院。结论　系统有效的术前及术后护理以及针对性心理护理是提高手术成功率、减少术后并发症的重要保证。     

現代外側開眶術

目的外側開眶術是治療眼眶中、後部腫瘤及泪腺腫瘤的一種標準術式,本文主要討論現代外側開眶術手術方法及適應癥.方法采用標準外側開眶,"S"形外側開眶和外側結合内側開眶術三種術式共做70例眼眶腫瘤.結果采用標準外側開眶適合于視神經以下腫瘤的切除(38例),"S"形外側開眶適合于視神經以上腫瘤的切除(28例),外側結合内側開眶適合于視神經周圍廣泛腫瘤的切除(4例).均獲較好效果.結論根據腫瘤的性質,位置和範圍采用不同術式的外側開眶.包括眶上、下緣的外側開眶使術野明顯擴大,提高J手術的成功率.     

Diagnosis of orbital mass lesions: clinical,radiological, and pathological recommendations

The orbit can harbor mass lesions of various cellular origins. The symptoms vary considerably according to the nature, location, and extent of the disease and include common signs of proptosis, globe displacement, eyelid swelling, and restricted eye motility. Although radiological imaging tools are improving, with each imaging pattern having its own differential diagnosis, orbital mass lesions often pose a diagnostic challenge. To provide an accurate, specific, and sufficiently comprehensive diagnosis, to optimize clinical management and estimate prognosis, pathological examination of a tissue biopsy is essential. Diagnostic orbital tissue biopsy is obtained through a minimally invasive orbitotomy procedure or, in selected cases, fine needle aspiration. The outcome of successful biopsy, however, is centered on its representativeness, processing, and interpretation. Owing to the often small volume of the orbital biopsies, artifacts in the specimens should be limited by careful peroperative tissue handling, fixation, processing, and storage. Some orbital lesions can be characterized on the basis of cytomorphology alone, whereas others need ancillary molecular testing to render the most reliable diagnosis of therapeutic, prognostic, and predictive value. Herein, we review the diagnostic algorithm for orbital mass lesions, using clinical, radiological, and pathological recommendations, and discuss the methods and potential pitfalls in orbital tissue biopsy acquisition and analysis.     

Visual Outcomes Following Orbital Biopsy

Abstract

Background: The risks of orbital biopsy depend on the lesion’s location and relationship with surrounding structures. Complications include reduced vision, although visual outcomes following orbital biopsy are not widely reported.

Aims: To determine visual outcomes following orbital biopsy in Gartnavel General Hospital’s Oculoplastic and Oncology Service.

Methods: Case note review of 50 consecutive patients undergoing orbital incision or excision biopsy between January 2006 and December 2010. Data collected included preoperative clinical examination, radiological and histological features, preoperative and postoperative corrected distance visual acuity (CDVA) and surgical complications. The main outcome measure was change in CDVA. Mean follow-up duration was 1.32 years.

Results: Histological diagnoses following biopsy included idiopathic orbital inflammation (n?=?13) and lymphoma (n?=?9). Of the radiologically defined lesions, 86.7% were extraconal (13.3% intraconal). Extraconal lesions were anterior in 59.0% (41.0% posterior). Mean preoperative LogMAR CDVA was 0.10 which was maintained at day one post-biopsy, indicating the absence of immediate sight-threatening complications such as retrobulbar haemorrhage or optic nerve compression, and there was no significant reduction at one-year follow-up (p?=?0.239). Further analysis of change in CDVA showed no difference between: anterior and posterior lesions; extraconal and intraconal lesions; incision and excision biopsies; anterior and lateral surgical approaches.

Conclusions: CDVA is retained for one year following orbital biopsy. Significant visual loss is a very rare complication of this procedure.     

外侧开眶术的临床疗效观察

目的：观察外侧开眶术的临床疗效。方法：采用标准外侧开眶、改良外侧开眶及外侧结合内侧开眶3种术式对武警总医院眼科1999年7月至2001年4月球后肌锥内及泪腺区肿瘤患者70例进行治疗,并观察其临床疗效。结果：标准外侧开眶术切除视神经及视神经下方肿瘤38例;改良外侧开眶术切除视神经上方及泪腺区肿瘤28例（包括眶上、下缘的切除）;外侧结合内侧开眶术切除视神经周围广泛肿瘤4例。术中全切肿瘤63例,3例行眼眶减压,3例血管畸形大部切除,1例眶尖海绵状血管瘤部分切除;眼球突出度：术后残余2mm眼球突出者3例,均为血管畸形。眼球内陷2－3mm者7例,均为体积较大肿瘤切除后所致,如海绵状血管瘤、血管畸形及泪腺肿瘤等。视力提高＞2行者31例,视力下降或丧失者6例,无变化者24例,失访9例未记录。眼球运动永久性障碍者7例,上睑下垂者2例。结论：应根据眼眶肿瘤的性质、位置及范围采取不同术式的外侧开眶术,包括眶上、下缘的骨瓣切除使术野扩大,并可明显提高眶内上和眶外上深部和眶尖肿瘤切除的成功率。     

眼眶骨瘤的手术技巧和疗效分析

目的 探讨眼眶骨瘤的手术技巧和疗效.方法 系列病例研究.回顾性分析19例眼眶骨瘤患者的临床资料,患者的诊断均经手术和病理检查结果证实.结果 骨瘤位于眶内侧10例,眶顶4例,眶外侧5例.手术入路为前路开眶8例,外侧开眶7例,内侧开眶2例,鼻侧切开2例.完全切除病变12例,大部分切除7例.结论 眼眶骨瘤临床诊断容易,但手术治疗困难,选择合适的手术入路、娴熟的手术技巧,可避免术中和术后合并症的出现.     

眼眶内海绵状血管瘤手术进路的临床分析

目的 探讨海绵状血管瘤手术进路的适应证选择、手术方法及技巧。方法 回顾性分析2002年7月～2003年3月武警总医院眼眶病研究所手术治疗的海绵状血管瘤20例。其中10例采用结膜入路，4例采用外侧开眶术，6例采用前路开眶术。结果 除1例结膜入路因粘连重改外侧开眶，1例因大出血加前路切开放血引流，其余均顺利取出瘤体，无明显并发症。结论 安全、有效地摘除海绵状血管瘤选择手术进路很重要。关键在于术前对肿瘤性质、位置、粘连程度的正确判断和手术操作的技巧。     

Orbital wall approach with preoperative orbital imaging for identification and retrieval of lost or transected extraocular muscles.

PURPOSE: To report the results of an anterior approach along the orbital wall to recover a lost or transected extraocular muscle. METHODS: This is a retrospective review of lost or transected muscles retrieved by an anterior orbitotomy approach to the adjacent orbital wall because they were unable to be recovered by a standard conjunctival approach. Magnetic resonance imaging or computed tomography was performed on all subjects before surgery. RESULTS: Six patients underwent anterior orbitotomy via an orbital wall approach; all had undergone an attempted retrieval from a standard transconjunctival approach that failed. Five muscles had been lost from surgical or traumatic transection, and 1 muscle had been lost during strabismus surgery. The muscle location at retrieval ranged from 20 to 25 mm (mean, 23 mm) posterior to the limbus. The duration that these muscles were disinserted ranged from 7 days to 7.5 years (mean, 24 months). Preoperative deviation in primary gaze ranged from 15 to 50 PD, whereas first day postretrieval deviations all measured less than 8 PD. After a mean follow-up of 162 weeks, the mean deviation in primary gaze was 2 PD (range, orthotropia to 7 PD of esotropia). CONCLUSIONS: Anterior orbitotomy along the orbital wall with preoperative orbital imaging of extraocular muscle anatomy and function combine to create a valuable approach for retrieval of a lost or transected muscle. This technique may successfully retrieve lost or transected muscles that previously were irretrievable when using a standard transconjunctival approach.