内镜下经筛径路眶内侧壁减压联合脂肪减压术治疗Graves眼病

目的 探讨内镜下经筛径路眶内侧壁减压术联合内镜下经筛径路眶肌锥内脂肪减压术治疗Graves眼病(Graves' ophthalmopathy,GO)的可行性,并分析其疗效.方法 对2006年10月至2011年5月因并发眶尖拥挤视神经病变而接受眶减压手术的29例GO患者进行回顾性分析.所有患者术前确诊为非组织活动期,均因视力下降、视野缺损或色觉障碍,同时合并眼球突出而接受内镜下经筛径路眶内侧壁减压术联合肌锥内眶脂肪减压术,术后定期随访.根据术后9个月视力、色觉改善程度,以及眼球突出度矫正度、复视等并发症判断疗效.结果 共收集资料齐全的GO患者29例(45眼).术后9个月,44眼(97.8％)视力明显改善,视力从术前((x)±s,下同)的-0.65±0.30提高至-0.24±0.22,视力平均提高达0.55 ±0.17,手术前后比较差异有统计学意义(t=- 13.012,p＜0.001);29眼术前色觉障碍者,23眼(79.3％)术后明显改善;术后双眼眼球对称度达100％,手术前后比较,平均眼球突出矫正度达(7.07±1.59) mm(4～11 mm).术后所有病例双眼眼球突出度相差＜2 mm,除1例术后复视加重外,术后无一例新发复视、视力下降、眶内出血等并发症发生.结论内镜下经筛径路眶内侧壁减压术联合肌锥内眶脂肪减压术在实现眶尖部减压的同时可以达到有效矫正眼球突出度的效果,且具有微创,无颜面部瘢痕,术后复视、眼球移位等发生率极低的优点,该术式是治疗GO并发眶尖拥挤视神经病变患者的安全有效的手段之一.     

鼻内镜下眶减压术治疗Graves’病进展

鼻内镜眶减压术治疗Graves’病是鼻内镜手术在鼻眼相关学科的又一应用，本对目前该手术各种术式、结果、手术并发症及处理方法等作一简要综述。     

鼻内镜下经鼻眶减压术治疗甲状腺机能障碍性眶病

目的　探讨甲状腺机能障碍性眶病的眶减压手术方法及其疗效。方法　对 9例 15眼患甲状腺机能障碍性眶病并严重影响视觉功能和容貌者 ,行内镜下经鼻眶减压术。结果　术后随访6个月～ 2年 (平均 1年 ) ,眼球突出度、视力、平视睑裂高度分别从术前的 ( 2 1 93± 1 49)mm、0 5 7±0 12、( 11 0 7± 1 44 )mm改善为术后 1年的 ( 16 87± 1 2 5 )mm、0 69± 0 12、( 8 2 0± 1 15 )mm。术后眶压较术前明显降低 (P <0 0 0 1)。 7眼复视 ,术后 3眼复视消失。结论　由操作熟练的耳鼻咽喉科医师行内镜下经鼻眶减压术 ,具有视野清晰 ,手术精确、安全 ,创伤小 ,并发症少等优点 ,是治疗甲状腺机能障碍性眶病的较好手术方法     

鼻内镜下经鼻眶减压术治疗甲状腺机能障碍性眶病

OBJECTIVE: To evaluate the effect of endoscopic transnasal orbital decompression for patients with dysthyroid orbitopathy. METHODS: Nine cases (15 eyes) of dysthyroid orbitopathy were included in this study. All patients were treated by transnasal endoscopic orbital decompression. RESULTS: The follow-up ranged from 6 months to 2 years. Proptosis measured' by exophthalmoter reduced from (21.93 +/- 1.49) mm to (16.87 +/- 1.25) mm after operation. The visual acuity improved from 0.57 +/- 0.12 to 0.69 +/- 0.12, the palperbral fissures reduced from (11.07 +/- 1.44) mm to (8.20 +/- 1.15) mm. Postoperatively, the orbital pressure was significantly decreased as compared with the preoperative result (P < 0.001). Diplopia was cured in 3 of 7 cases. CONCLUSION: Endoscopic transnasal orbital decompression is an effective method for the treatment of dysthyroid orbitopathy.     

改良内镜辅助眶内外壁减压治疗活动期难治性Graves眼病视神经病变的临床效果

目的　探讨改良内镜辅助眶内外壁减压治疗活动期难治性Graves眼病视神经病变的远期效果。方法  对2017年3月～2019年3月中山大学孙逸仙纪念医院甲状腺眼病多学科诊疗组收治的9例激素冲击后视力恶化的患者行急诊减压手术,采用内镜辅助内壁减压联合经重睑延长切口的内镜辅助深外侧壁减压的个体化手术。观察术后1年患者临床活动性评分（clinical activity score,CAS）、视力、眼内压、眼球突出度及生活质量等指标。应用SPSS 26.0软件对数据进行统计学分析。结果　术后随访1年以上,患者CAS分值、视力、眼压、眼球突出度及生活质量改善,差异有统计学意义。术后1年仍有复视3例,斜视3例。结论　个体化改良内镜辅助的深外侧壁联合内侧壁减压手术对活动期难治性Graves眼病视神经病变具有肯定疗效。     

眶悬带技术在内镜眶减压术中的应用

目的 总结在经鼻内镜眶减压术中应用眶悬带技术,以降低术后复视发生率的初步经验.方法 6例共11眼行经鼻内镜眶壁减压术.其中包括5例(10眼)Graves眼病和1例(1眼)外伤后病例,手术采用眶悬带技术,即保留眼眶内壁赤道高度条带状眶骨膜以稳定内直肌及眼球,避免其过度疝入眶内而改变其运动矢量.对比术前、术后眼球突出度、复视、眼痛、结膜充血等变化.结果 术后患者眼球突出度减少2～5mm,平均回缩3.2mm.术前2例存在复视,术后复视减轻,其余4例无术后复视发生.5例Graves眼病患者眼胀痛消失,结膜充血减轻,眼球活动度及外观改善.1例外伤痛例双眼突出度接近,外观改善.结论 在经鼻内镜眶减压术中保留位于内直肌内侧的条带样眶骨膜,使之成为稳定内直肌及眼球的悬带.该技术能够在保证眶脂肪自悬带上下方溢出而减压的同时,可有效预防术后复视的发生.     

经鼻内镜下视神经管减压术

目的：探讨颅脑外伤并视神经损伤的有效疗法。方法：经鼻内镜进行视神经管减压术。结果：4例中有3例术后视力增进，其中1例术后2个月由术前的光感增进至1．0，结论：一旦确诊为视神经管骨折应尽早手术，经鼻内镜手术是可选择的方法之一。     

鼻内镜下筛蝶窦入路视神经管减压术

视神经管减压术治疗因外伤导致的视神经管骨折引起的同侧眼视神经损伤、视力下降或失明,临床并不罕见。结合我院及上海第二军医大学附属长征医院1996年11月~2004年1月收治的14例患者,就其发病机制和诊治情况分析报告如下。1资料与方法1.1临床资料本组14例患者,男12例,女2例;年龄7~58岁,平均29岁。受伤原因:车祸伤9例,坠楼伤3例,拳击伤1例,雨伞戳伤1例。并发颅脑损伤4例,颌面骨折2例。受伤到手术时间为4~137 d。平均35.3 d。本组病例患眼均失明,当即失明2例,第2天失明4例,无法确定8例。1.2手术方法全身麻醉插管加中鼻道表面麻醉,矫正患侧的高…     

三壁微创眼眶减压术治疗甲状腺相关眼病的疗效分析

目的 观察三壁微创眼眶减压术治疗甲状腺相关眼病的临床疗效.方法 对5例（8眼）重度突眼患者施行三壁微创眼眶减压术,随访观察比较手术前后的临床表现变化、手术效果及并发症情况.结果 术后存在角膜刺激症状或溃疡者均治愈 5眼视力有不同程度的提高,3眼无变化 眼球后退5～8 mm,平均6.2 mm 术后均出现不同程度的复视,经治疗于2～3周内消失 无其他手术并发症发生.结论 对重度突眼患者,三壁微创眼眶减压术能减轻眼球突出程度、提高视力、改善美容,是一种安全、有效、并发症少的治疗手段.     

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。     

Endoscopic orbital decompression for Graves' ophthalmopathy

BACKGROUND: Graves' ophthalmopathy generates a volume excess for the orbital cavity, which may produce proptosis, pain, exposure keratitis, diplopia, and optic neuropathy. Endoscopic orbital decompression expands the orbital cavity into the ethmoid cavity and medial maxillary sinus. This retrospective study documents the outcomes after endoscopic orbital decompression for patients with Graves' ophthalmopathy. METHODS: Data collected included demographic information, symptom resolution, complications related to the surgery, reduction in proptosis, subsequent need for eye muscle surgery, and hospital length of stay. Between July 1989 and April 2003, 62 patients were referred for endoscopic orbital decompression (often unilateral). RESULTS: Three patients refused use of their medical records for research purposes. Seventy percent were women; the average age of the study group was 49 years. Preoperatively, 63% of the patients had diplopia and optic neuropathy was noted in 27%. Two patients had a cerebrospinal fluid leak identified and managed during the decompression. No postoperative leaks occurred. Twenty-five percent of patients did not require eye muscle surgery. Forty-eight percent of the patients underwent one procedure to manage diplopia. The average reduction in proptosis was 2.5 mm. Fifty-four percent were managed as an outpatient and 27% underwent a 23-hour observation period. CONCLUSION: This data supports the safety, efficiency, and efficacy of endoscopic orbital decompression for unilateral and bilateral Graves' ophthalmopathy. Eye muscle surgery frequently will be required to manage diplopia after decompression.     

Endoscopic orbital decompression for Graves' ophthalmopathy

Graves' disease may occasionally result in significant proptosis that is either cosmetically unacceptable or causes visual loss. This has traditionally been managed surgically by external decompression of the orbital bony skeleton. Trans-nasal endoscopic orbital decompression is emerging as a new minimally-invasive technique, that avoids the need for cutaneous or gingival incisions. Decompression of the medial orbital wall can be performed up to the anterior wall of the sphenoid sinus. This can be combined with resection of the medial and posterior portion of the orbital floor (preserving the infra-orbital nerve). This technique produces decompression which is comparable to external techniques. We present a series of 10 endoscopic orbital decompressions with an average improvement of 4.4 mm in orbital proptosis. There was an improvement in visual acuity in all patients with visual impairment. Endoscopic orbital decompression is recommended as an alternative to traditional decompression techniques.     

Ancillary procedures in microscopic endonasal orbital decompression for thyroid-associated ophthalmopathy

In 35 patients with thyroid-associated orbitopathy, nonresponsive to conservative treatment, an endonasal microscopic approach with bimural osteotomy was performed for decompression in two ways. While in group A the periorbita was resected, and fat septa were cut, in group B periorbital strips were left, and fat septa were respected. In accordance with other authors, resection of the periorbital and cutting fat septa will improve vision and proptosis, but in up to 30% of the patients de novo diplopia occurs. Our data favor the assumption that a more conservative endonasal microscopic decompression of the orbita leaving periorbital strips and fat septa achieves similar good results for reduction of proptosis and visual gain but creates less often de novo diplopia in primary gaze. Based on our experience, rehabilitation for thyroid-associated arbitopathy comprises as a first step orbital endonasal decompression with cooperation of the ophthalmologist, then if necessary as a second step strabismus surgery, and thirdly eyelid repair for scleral show.     

Reduction of diplopia following endoscopic orbital decompression: the orbital sling technique

OBJECTIVE: Although endoscopic orbital decompression has become the surgical treatment of choice for patients with proptosis from Graves disease, postoperative diplopia requiring corrective eye muscle surgery can occur in up to 63% of patients. The purpose of the study was to evaluate a new technique intended to reduce the incidence of diplopia following endoscopic orbital decompression. STUDY DESIGN: Case-control. METHODS: Endoscopic orbital decompression was performed on 58 orbits in 37 patients with proptosis from Graves disease. The orbital sling technique, which makes use of a horizontal strip of periorbital fascia to prevent prolapse of the medial rectus muscle, was used on 20 orbits in 13 patients. Conventional endoscopic decompression was performed in 24 control subjects. The mean duration of follow-up was 3.3 +/- 1.3 years (range, 1.7-5.1 y). RESULTS: The incidence of new-onset or worsened diplopia following endoscopic decompression was significantly lower for the orbital sling group compared with control subjects (0% vs. 29.2%, respectively [ =.038]). No patients in the orbital sling group developed new-onset diplopia following surgery. Of the eight patients with pre-existing diplopia from the orbitopathy, double vision improved in four patients (50%) and was unchanged in the remaining four patients (50%). The mean reduction in proptosis was comparable for the orbital sling and control groups (5.1 +/- 1.1 mm vs. 5.0 +/- 1.9 mm, respectively [ P=.98]). CONCLUSIONS The preservation of a fascial sling overlying the medial rectus muscle during endoscopic orbital decompression appears to reduce the incidence of postoperative diplopia, while still allowing for a satisfactory reduction in proptosis. This modification of the standard decompression technique should be considered for the treatment of patients with proptosis.     

Transantral orbital decompression for Graves’disease

Seventy-five patients with Graves’disease have been treated by transantral orbital decompression. In the first post-operative month the average reduction in proptosis was 3 mm. In the years following the operation this reduction increased to an average of 4.5 mm. In 32% of the patients without diplopia before surgery, the diplopia that developed afterwards did not disappear, 83% of them were successfully treated by extraocular muscle surgery. Seventy per cent of the patients experienced immediate post-operative improvement of visual acuity. Only three patients remained with anaesthesia of the infra-orbital nerve. A total of 65% of the patients found the operation procedure beneficial while 76% were satisfied with the ophthalmological result. We conclude, that transantral orbital decompression, though with moderate morbidity, gives good results in patients with the orbital complications of Graves’disease.     

甲状腺相关性眼病的诊断及治疗进展

甲状腺相关性眼病是一种与甲状腺功能异常相关的器官特异性自身免疫性疾病,该病最常见的是腺外器官受累,从而影响患者外观;重者可以导致复视、视力下降甚至失明,然其发病机制尚不完全清楚,目前临床上的治疗并不能达到100%满意。且临床上治疗方法有多种。实验室检查其主要的病理改变是眼睛的软组织和眼外肌的一些免疫炎性反应,但是确切的发病病理生化等机制尚不清楚。临床上诊疗难度大,就本病在临床诊断及治疗的最新研究进展进行综述。     

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).