A型肉毒毒素治疗甲状腺相关性免疫眼眶病上睑退缩临床研究

目的：探讨提上睑肌注射A型肉毒毒素治疗甲状腺相关性免疫眼眶病上睑退缩临床效果。方法：对58例（62眼）甲状腺相关性免疫眼眶病上睑退缩采用A型肉毒毒素注射于提上睑肌,根据上睑退缩轻中重程度分别给予3u、5u、7u。观察上睑缘下降幅度。结果：54眼注射A型肉毒毒素后约3．5天出现麻痹效果,可持续4－20周,下降程度在3－4mm之间。主要并发症为上直肌功能减退或复视。结论：提上睑肌注射A型肉毒毒素能在一定时间有效治疗甲状腺相关性免疫眼眶病上睑退缩,对改善外观和保护角膜有很大意义。     

A型肉毒毒素辅助治疗Graves眼病的临床观察

目的通过对存在恶性突眼的Graves眼病患者受累眼外肌进行A型肉毒毒素注射治疗,观察注射后眼位偏斜及复视恢复的情况,探讨A型肉毒毒素辅助治疗Graves眼病的机理及实用价值。方法选取我院确诊为伴有恶性突眼的Graves眼病合并眼位偏斜的患者31例(其中伴有水平偏斜者15例,伴有垂直偏斜者30例)。患者进行眼眶CT扫描、同视机、HESS屏和斜视度测定等检查后,对其所受累的眼外肌(下直肌24条,内直肌11条,上直肌6条,上睑提肌4条)在肌电图的指引下进行多次重复的A型肉毒毒素肌腹内注射。定期随诊观察注射后的眼位变化及复视程度的变化。结果31例接受A型肉毒毒素眼外肌注射的患者中,在经过重复注射2~6次后,其斜视度及复视程度均有不同程度的减轻。总体显效率41.9%,有效率51.6%,无效率6.5%.结论A型肉毒毒素眼外肌内注射是一种能有效缓解Graves眼病患者眼外肌挛缩和减轻复视症状及斜视度的治疗方法。在疾病早期及时应用A型肉毒毒素进行受累眼外肌注射,并适当联合全身或局部激素、免疫抑制剂治疗,对于控制Graves眼病的临床症状可以收到满意的疗效。     

甲状腺相关眼病上睑退缩的治疗

目的：探讨甲状腺相关眼病上睑退缩的治疗方法。方法：回顾分析临床资料完整的90例123眼甲状腺相关眼病上睑退缩的治疗效果。治疗方法包括保守观察、全身和局部糖皮质激素治疗、局部肉毒杆菌毒素注射和手术治疗等。治疗后平均随访1．4年。结果：用全身和局部糖皮质激素治疗34例49眼中，上睑退缩完全消失4例6眼，明显改善13例20眼，无效17例23眼；局部肉毒杆菌毒素注射20例26眼中，上睑退缩完全消失8例9眼，明显改善9例11眼，无效3例6眼，持续时间6w至2年，注射后并发上睑下垂4例5眼；提上睑肌延长术11例15眼中，术后上睑退缩完全消失7例10眼，明显改善2例3眼，复发1例1眼，轻度过矫1例1眼；上睑退缩伴患眼下斜视15例15眼，行患眼下直肌后退术，其中术后上睑退缩完全消失14例14眼，明显改善1例1眼；10例18眼未作任何治疗，经平均2年随访观察发现2例4眼上睑退缩完全消失，1例2眼有明显改善。结论：甲状腺相关眼病上睑退缩宜采用综合治疗措施。发病初期或活动期病例用全身和局部糖皮质激素和局部注射肉毒杆菌毒素治疗效果好，静止期或保守治疗效果不好的患者宜行提上睑肌延长术治疗，伴有下斜视的患者行斜视矫正术可同时矫正斜视与上睑退缩。     

结膜下注射肉毒杆菌毒素治疗甲状腺眼病的上睑退缩

甲状腺眼病 (thyroideyedisease,TED)中的上睑退缩、上方巩膜暴露 ,除导致角、结膜暴露性疾病外 ,也因影响美观而引起患者的心理压力。常规手术治疗步骤复杂 ,有一定风险。对不适合或不愿接受手术治疗的患者 ,常规保守治疗不能令人满意。肉毒杆菌毒素A(bo tulinumtoxintypeA ,BTTA)是作用于神经 肌接头处的神经毒素 ,常用于治疗特发性睑痉挛、斜视、第六对颅神经麻痹、眼球震颤及睑内翻等眼病。该研究介绍了结膜下注射BTTA治疗TED患者上睑退缩的方法、效果、患者满意度及副作用。研究中选择的 11例患者 (16眼 )均为甲状腺功能正常或…     

肉毒杆菌毒素A治疗甲状腺相关性眼病的限制性眼肌病对眼压的影响

眼外肌受累是甲状腺相关性眼病的特征 ,常累及下直肌和内直肌 ,导致限制性眼肌病 ,引起第一眼位和向上注视时眼压升高。曾有报道注射肉毒杆菌毒素A治疗限制性眼外肌病可提高患者眼球活动度、减轻复视、降低眼外肌的牵拉作用 ,但未见有研究注射肉毒杆菌毒素A影响眼压的报道。该文介绍观察眼外肌内注射肉毒杆菌毒素A对甲状腺相关性眼病患者眼压的影响。回顾加里福尼亚圣地亚哥甲状腺眼病中心1 997年 1 2月～ 1 998年 1 2月接受肉毒杆菌毒素A注射的 8例甲状腺相关性眼病患者的临床资料。注射前、后分别测量患者第一眼位和向上注视时眼压。注…     

肉毒杆菌毒素A治疗婴幼儿型内斜视的新进展

肉毒杆菌毒素由于具有可逆性、副作用小、临床使用操作简便等优点，在多种类型的斜视、眼睑痉挛、上睑退缩等疾病治疗方面的研究日益深入。近年来，肉毒杆菌毒素A注射眼外肌治疗婴幼儿型内斜视，不仅比手术治疗方法简便，而且将治疗时间提前，为患儿早期视功能的建立提供了新的思路和方法，本文就此方面的临床研究和应用作一综述。     

本期导读

本期报道的重点内容是我国甲状腺相关眼病(TAO)的临床与基础研究。本期的“专家述评”约请罗清礼就眼眶脂肪组织在TAO中作用进行了评述。他分析了近年来对眼眶脂肪细胞在TAO发病中作用的研究现状,指出TAO患者眼眶脂肪组织的体积和细胞数量均有增加,不但直接导致眼眶压增高、眼球突出及视力损害,而且脂肪组织分泌的多种因子和蛋白分子参与了TAO的发生与发展。他的看法值得重视。本期的“焦点论坛”约请肖利华就恰当的TAO治疗发表了看法。他指出虽然TAO的治疗较为复杂,多数患者需要采用综合治疗措施,但关键问题在于准确掌握TAO的临床特征,并根据每个患者的具体情况选择恰当的个体化治疗方案。由于眼外肌的肥大,TAO患者常有复视和眼外肌运动障碍,对于这种限制性斜视一般给予手术治疗。但在TAO病情稳定前,并不是手术的适当时机。只有经过内科治疗后,待甲状腺功能正常、眼眶炎性反应静止及斜视度稳定后再行手术治疗。这一过程往往需要患者等待半年,甚至更长时间,而给患者造成痛苦。吴晓等应用A型肉毒毒素眼外肌注射治疗33例TAO引起的限制性斜视患者,减轻了斜视度和复视症状,获得了良好的临床效果,为这类患者的治疗提供了有益的启示。迅速准确地判断TA...     

甲状腺相关性眼病的临床特征

目的回顾性分析56例甲状腺相关性眼病(thyroid associated ophthalmopathy,TAO),提出TAO不典型病例的临床特征,为早期进行临床诊断提供依据.方法总结56例TAO患者的主诉、眼征、斜视度、眼球运动等临床特征和眼外肌的影像学检查结果,进行统计学分析.结果本组有94.7%的患者表现为眼球运动受限,83.9%的病例以复视为主诉就诊,53.6%出现眼球突出,46.4%出现眼睑退缩和迟落.TAO以多条眼外肌受累为特点,眼外肌厚度增加以上直肌最为明显,以上转运动受限频率最高(69.6%).本组TAO的发生先于甲状腺功能异常23人(41.1%),其中有9人(16.1%)是TAO发生1年以上才发生甲状腺功能异常的.结论大多数TAO患者依据其临床表现易于确诊,对不典型患者应注意眼征特点,分析眼外肌受累的情况,并排除其他原因引起的限制性斜视.牵拉试验和影像学检查对确诊有重大意义.     

甲状腺相关眼病限制性斜视手术并发症的临床分析

目的:总结甲状腺相关眼病(thyroid associate dophthalmopathy,TAO)导致的限制性斜视手术并发症的常见原因及应对策略。方法:回顾性分析于2009-01/2012-02在我院就诊的21例眼外肌手术出现并发症的TAO限制性斜视病例,分析手术前病情、手术情况、手术并发症等临床资料。结果:患者21例中术前有6例为限制性上斜视,15例为限制性下斜视。手术中行上直肌断腱1例,后退5例,下直肌后退15例。术中发生巩膜损伤2例,其中1例在断肌止点时损伤巩膜,1例在将肌肉固定于巩膜上时缝穿巩膜;术中预置缝线滑脱3例;术后早期(术后1mo内)发生欠矫6例,过矫5例;术后晚期(术后6mo后)出现过矫15例,包括6例限制性上斜视患者、9例限制性下斜视;下睑退缩8例。结论:TAO限制性斜视手术矫正容易出现过矫,手术中应严格控制肌肉后退量,下直肌后退时应注意下睑退缩发生的可能。     

高频超声引导下A型肉毒杆菌毒素注射在甲状腺相关眼病限制性斜视中的应用

目的:探讨高频超声引导下注射A型肉毒杆菌毒素(botulinum toxin A,BTXA)治疗甲状腺相关眼病(thyroid associated ophthalmopathy,TAO)限制性斜视的临床效果。方法:选择32例TAO限制性斜视患者,在眼科高频超声引导下注射BTXA。观察注射前后的斜视度及复视的变化情况。结果:患者32例经重复注射2～4次BTXA后,其斜视度及复视情况有不同程度的减轻。总体显效率占47%,有效率占44%,无效率占9%。结论:高频超声引导下注射BTXA治疗TAO限制性斜视,定位准确,是一种有效缓解眼外肌痉挛和减轻复视症状及斜视度的方法。     

Management of strabismus with botulinum A toxin

Three hundred eight patients with strabismus were treated with botulinum A toxin (Oculinum) chemodenervation; 153 were followed by the authors for at least 6 months. In this study group, 97 received botulinum A toxin injections as the primary method of treatment of their ocular deviation. Fifty-six received injections after traditional extraocular muscle surgery. Botulinum A toxin was useful for management of patients with recent surgical overcorrections and for management of some patients with sixth cranial nerve palsy. Chemodenervation of an extraocular muscle was not as successful as traditional strabismus surgery for treatment of infantile esotropia and other comitant deviations. Botulinum A toxin injection was ineffective in patients who had restrictive strabismus. This drug has limited application in the management of patients with strabismus.     

A型肉毒毒素在甲状腺相关眼病限制性斜视治疗中的应用

目的探讨A型肉毒毒素(BTXA)治疗甲状腺相关眼病(TAO)限制性斜视的疗效及作用特点。方法回顾性分析BTXA眼外肌注射治疗TAO限制性斜视的临床资料,在肌电图的引导下,对33例TAO限制性斜视患者的眼外肌肌腹注射BTXA,注射前后记录眼位、眼球运动、复视等情况。结果本组患者垂直斜视25例,水平斜视3例,水平斜视合并垂直斜视5例。水平斜视度平均35·00△±20·53△(20△~80△,M=27·5△),垂直斜视度29·33△±17·27△(10△~100△,M=27·5△)。随诊时间5·00~67·73个月,平均(17·04±12·77)个月。注射眼外肌61条,其中下直肌31条,内直肌16条,上直肌10条,外直肌4条。每条眼外肌平均注射次数(6·48±2·12)次,(4~11次,M=6次)。注射间隔时间0·50~26·00个月,平均(2·96±0·70)个月。注射后斜视度减小,治愈15例,有效12例,治疗无效6例。单次注射用药剂量平均(8·16±1·43)U。结论BTXA治疗TAO引起的限制性斜视效果良好。注射时机以TAO早期为佳。每次注射BTXA剂量大于麻痹性斜视和共同性斜视的用量,矫正的斜视度较低,注射的间隔时间和疗效持续时间较短,随治疗次数的增加,注射剂量需不断增大。部分患者可能免除复视而不需手术。     

甲状腺相关眼病上睑退缩的诊断和治疗

甲状腺相关眼病(TAO)常表现为上睑退缩、结膜充血水肿、眼球突出、复视、斜视、视力下降等,疾病早期确诊有一定困难.TAO患者往往在病程早期即出现上睑退缩,影响外观,造成不适感和视力减退,增加对上睑退缩的了解有助于TAO的早期诊治.TAO上睑退缩患者往往具有典型的横向耀斑征,即上睑颞侧退缩更明显,但仍容易漏诊,需与先天性上睑退缩、部分神经系统疾病、高度近视突眼、青光眼滤过泡等相鉴别,同时综合考虑患者家族史、临床表现和TAO相关的辅助检查以确诊.TAO上睑退缩宜采用综合治疗措施.推荐全身或局部糖皮质激素治疗或手术治疗.目前,应用糖皮质激素的具体剂量仍存在一定争议,但建议1个阶段的治疗中累积剂量不超过8 g,否则易引起肝衰竭等不良反应的发生.根据患者病因和退缩程度的分级,应选择不同的手术方法,对各类型患者采取适合的治疗方案.另外,术中还应特别注意颞侧肌力的减弱.TAO上睑退缩的诊治常需个体化分析,早诊断、早治疗可有效改善患者的容貌外观和视功能,提高患者的生活质量.     

肌腹下眶-球硅管连接术与肌腹下注射A型肉毒素治疗麻痹性斜视的效果对比

目的　探讨在麻痹肌肌腹下行眶-球硅管连接术与肌腹下注射Ａ型肉毒素治疗麻痹性斜视的疗效对比。方法　收集３６例（３６眼）斜视患者,根据治疗方法不同分为两组,Ａ组行肌腹下眶-球硅管连接术,Ｂ组行Ａ型肉毒素眼外肌注射治疗,每组各１８例（１８眼）。记录术后１周与６ａ时两组患者的临床效果、角膜散光、视功能及屈光度变化等情况。结果　Ａ组患者术后均达到美容性眼位矫正;１２例（６６．７％）达到功能性眼位矫正;治疗１周后角膜前表面屈光度、散光值及散光轴向与治疗前相比明显增加,治疗６ａ后角膜前表面屈光度、散光值及散光轴向基本恢复至术前水平;Ａ组术后１周８例患者存在双眼视功能,随访６ａ１４例存在双眼视功能。Ｂ组患者术后１２例（６６．７％）达到美容性眼位矫正;达到功能性眼位矫正者９例（５０．０％）;治疗１周后及随访６ａ角膜前表面屈光度、散光值及散光轴向与治疗前相比差异均无统计学意义（均为Ｐ＞０．０５）;Ｂ组术后１周６例患者存在双眼视功能,随访６ａ７例存在双眼视功能;两组治疗后１周近视度数相比差异无统计学意义（Ｐ＞０．０５）,随访６ａ,Ａ组近视度数为（－３．５２±２．８２）Ｄ,Ｂ组为（－５．７８±３．４２）Ｄ,Ａ组明显低于Ｂ组（Ｐ＜０．０５）。结论　肌腹下眶-球硅管连接术与肌腹下注射Ａ型肉毒素相比,在临床效果、角膜散光、视功能方面均有明显差异,眶-球硅管连接术是治疗麻痹性斜视的可行方法,值得推广。     

Botulinum toxin type a for dysthyroid upper eyelid retraction

PURPOSE: To evaluate the safety and efficacy of botulinum toxin type A for treatment of eyelid retraction resulting from thyroid eye disease (TED) during the inflammatory phase of the condition. METHODS: In this prospective, nonrandomized case series, 18 patients with inflammatory eyelid retraction caused by active TED received botulinum toxin type A injection (10, 5, or 2.5 U) for treatment of upper eyelid retraction. Botulinum toxin type A (Allergan, Irvine, CA, U.S.A.) was injected transconjunctivally just above the superior tarsal border in the elevator complex of the upper eyelid. RESULTS: Seventeen of 18 patients (94%) demonstrated a reduced marginal reflex distance (MRD1) after botulinum toxin injection. The average change in MRD1 of the treated eyelid after injection was -2.35 mm (range, 0 to -8.0 mm). Of the 27 eyelids injected, 33% had a 0- to 1-mm drop in eyelid height, 30% had a 1.5- to 2-mm decrease, 22% had a 2.5- to 3-mm decrease, and 15% had a greater than 3-mm decrease in eyelid height. None of the treated eyelids were noted to increase in height. One patient showed no alteration inafter treatment. One patient had clinically MRD1 significant ptosis and one patient reported worsening of preexisting diplopia after injection. Three patients undergoing unilateral injection had relative contralateral eyelid elevation. All untoward effects resolved spontaneously without sequelae. CONCLUSIONS:: Botulinum toxin type A may be used in the inflammatory stage of thyroid eye disease to improve upper eyelid retraction. Individual response to treatment is variable, but this modality should be considered as a temporizing measure until stability for surgery is reached.     

Injection treatment of endocrine orbital myopathy

Eight Patients with endocrine orbital myopathy received botulinum toxin injection of extraocular muscles for strabismus or injections of the levator for lid retraction. Strabismus of 25 prism diopters or less, especially during early stages of eye muscle involvement, responded well to injection with realignment and, probably, with avoidance of fixed muscle shortening. Long-standing strabismus, large angles, and lid retraction responded less well.     

Botulinum toxin A treatment of overactive corrugator supercilii in thyroid eye disease

BACKGROUND/AIM—Patients with thyroid eye disease with upper eyelid retraction often develop overaction of the accessory muscles of eyelid closure, the glabellar muscles corrugator supercilii and procerus. The resultant glabellar furrowing (frown lines) contributes to the typical thyroid facies. The aim of this study was to evaluate the use of botulinum toxin A reversible chemodenervation of the glabellar muscles as adjunctive treatment in the rehabilitation of patients with thyroid eye disease.
METHODS—14 patients (13 females) ages 39-76 years (mean 52) with inactive thyroid eye disease and associated medial eyebrow ptosis and prominent glabellar frown lines were recruited. All patients had a history of upper eyelid retraction. Each patient was treated with a single botulinum toxin injection (Dysport 0.2 ml, 40 units) into each corrugator supercilii and sometimes procerus muscles as an outpatient procedure. The effectiveness and acceptability of the treatment was assessed clinically and from a patient questionnaire.
RESULTS—The injections were tolerated by 13/14 (93%) patients. There was resultant flattening of the glabellar region and improvement of medial eyebrow contour in all patients, with onset of paralysis within 1 week. All patients reported a subjective improvement in appearance. Side effects included one patient (7%) with reversible partial ptosis. The beneficial effect lasted 4-6 months, with a gradual return of function. Repeat treatment was indicated where there was persistent upper eyelid retraction and protractor overaction.
CONCLUSION—Botulinum toxin A chemodenervation of the glabellar muscles in these patients was effective and acceptable. Chemodenervation should be considered in the rehabilitation of patients with thyroid eye disease where there is upper eyelid retraction and overacting protractors resulting in a thyroid frown. Once the eyelid retraction has been successfully treated by surgery, the need for further glabella muscle chemodenervation is considerably reduced.

Keywords: botulinum toxin A; corrugator supercilii; frown lines; thyroid eye disease     

Botulinum Toxin Injection into Extraocular Muscles as an Alternative to Strabismus Surgery

Sixty-seven injections of botulinum A toxin were given to patients for correction of strabismus. No systemic complications of any kind have occurred. The maximum time of paralysis occurs four to five days following the injection, and then gradually diminishes, depending on the dose. The maximum correction of strabismus has been 40 prism diopters. The maximum follow-up following injection is six months. Injection of botulinum A toxin into extraocular muscle to weaken the muscle appears to be a practical adjunct or alternative to surgical correction.     

Customized Orbital Decompression Surgery Combined with Eyelid Surgery or Strabismus Surgery in Mild to Moderate Thyroid-associated Ophthalmopathy

Purpose

To evaluate the efficacy and safety of customized orbital decompression surgery combined with eyelid surgery or strabismus surgery for mild to moderate thyroid-associated ophthalmopathy (TAO).

Methods

Twenty-seven consecutive subjects who were treated surgically for proptosis with disfigurement or diplopia after medical therapy from September 2009 to July 2012 were included in the analysis. Customized orbital decompression surgery with correction of eyelid retraction and extraocular movement disorders was simultaneously performed. The patients had a minimum preoperative period of 3 months of stable range of ocular motility and eyelid position. All patients had inactive TAO and were euthyroid at the time of operation. Preoperative and postoperative examinations, including vision, margin reflex distance, Hertel exophthalmometry, ocular motility, visual fields, Goldmann perimetry, and subject assessment of the procedure, were performed in all patients. Data were analyzed using paired t-test (PASW Statistics ver. 18.0).

Results

Forty-nine decompressions were performed on 27 subjects (16 females, 11 males; mean age, 36.6 ± 11.6 years). Twenty-two patients underwent bilateral operations; five required only unilateral orbital decompression. An average proptosis of 15.6 ± 2.2 mm (p = 0.00) was achieved, with a mean preoperative Hertel measurement of 17.6 ± 2.2 mm. Ocular motility was corrected through recession of the extraocular muscle in three cases, and no new-onset diplopia or aggravated diplopia was noted. The binocular single vision field increased in all patients. Eyelid retraction correction surgery was simultaneously performed in the same surgical session in 10 of 49 cases, and strabismus and eyelid retraction surgery were performed in the same surgical session in two cases. Margin reflex distance decreased from a preoperative average of 4.3 ± 0.8 to 3.8 ± 0.5 mm postoperatively.

Conclusions

The customized orbital decompression procedure decreased proptosis and improved diplopia, in a range comparable to those achieved through more stepwise techniques, and had favorable cosmetic results when combined with eyelid surgery or strabismus surgery for mild to moderate TAO.