眼眶减压术治疗甲状腺功能障碍性视神经病变

甲状腺功能障碍性视神经病变(dysthyroid optic neuropathy,DON)是甲状腺相关眼病的严重并发症之一。DON由于多病因导致眶内容物增多、眶内压增高,如延误治疗会造成不可逆性视力丧失。及时行眼眶减压术降低眶内压、减弱疾病活动性是治疗DON抢救视力、改善眼突度等的关键。眼眶减压术包括眼眶眶壁去除减压术、眶内脂肪切除减压术等。近年术式有所改进,包括深外侧壁减压术、内外壁平衡减压术、三壁最大化眶减压术、微创硬膜外眼眶减压术、鼻内镜下不同入路眶壁减压术、计算机辅助减压术、多种术式联合减压等,以期得到更好的治疗效果。(国际眼科纵览,2020,44:431-437)     

甲状腺相关眼病的影像学检查

甲状腺相关眼病(thyroid associated ophthalmopathy,TAO)是一种自身免疫性眼眶炎症性疾病,影像学检查是其重要的辅助检查手段。通过影像学检查能充分了解眶内病变,鉴别具有相似临床表现的眼眶疾病; 同时对TAO分期、辅助诊断压迫性视神经病变(compressive optic neuropathy,CON)也具有重要意义。     

继发于眼眶疾病的眼底病变18例临床分析

目的 探讨眼眶疾病合并眼底改变的临床特征以及二者的关系.方法 回顾分析合并眼底改变的18例眼眶疾病,其中甲状腺相关眼病3例,眼眶炎性假瘤2例,泪腺多形性腺瘤3例,眼眶视神经胶质瘤2例,视神经脑膜瘤2例,眼眶神经鞘瘤l例,眼眶副神经节瘤1例,眼眶非霍奇金淋巴瘤l例,眼眶海绵状血管瘤1例,眼眶脉管瘤并出血1例,后巩膜炎l例.结果 18例眼眶疾病的患眼均有不同程度的眼底改变.甲状腺相关眼病的眼底特征为视盘瘀血性水肿和黄斑皱褶;眼眶炎性假瘤的眼底特征为视盘水肿炎症;眼眶肿瘤的眼底改变表现为肿瘤压迫导致的脉络膜视网膜皱褶和隆起;若肿瘤位于视神经则易合并视乳头肿胀改变;累及眶尖部位则易形成眶内血液回流障碍,出现明显的眼底视网膜静脉扩张迂曲.结论 眼眶疾病引起的眼底改变主要为眶内肿物轻度压迫引起的脉络膜视网膜皱褶和明显压迫引起的脉络膜视网膜局部隆起;当眶内病变累及球后近端视神经则易导致视乳头肿胀,累及眶尖部位则易出现视网膜静脉扩张迂曲.眶内疾病合并眼底改变可能与其原发疾病性质、位置有关.     

甲状腺相关性眼病内镜微创减压术的历史与展望

甲状腺相关性眼病是成人最常见的眼眶疾病,眶减压手术是其重要的治疗手段。随着内窥镜技术的发展,内窥镜下眶减压手术逐渐成为其首选的手术方案。现将重点介绍内窥镜技术在眼眶内侧壁、外侧壁以及下壁减压中的应用进展,并介绍其手术效果以及并发症的预防与处理。同时介绍内窥镜下经筛径路眶减压手术在甲状腺相关性眼病视神经病变中的手术进展。     

甲状腺相关视神经病变的研究进展

甲状腺相关视神经病变是甲状腺相关眼病的继发性病变，临床表现包括视力下降、色觉受损、相对性传入性瞳孔障碍、视盘水肿或萎缩等。眼科辅助检查表现为视野异常和视觉诱发电位异常等，影像学检查显示眶尖拥挤可辅助诊断。目前此病的发病机制未明，既往研究提出其与视神经压迫、牵拉和缺血有关。治疗方法包括大剂量糖皮质激素静脉冲击治疗、眼眶减压手术、眼眶放射治疗和生物制剂等。本文主要回顾流行病学特征、发病机制及临床诊治等方面的进展，以期为临床实践和研究提供参考。     

医学影像学评估甲状腺相关性眼病活动度的价值

甲状腺相关性眼病（thyroid associated ophthalmopathy,TAO）是一种器官特异性自身免疫性疾病,其治疗方案的确定及疗效观察依赖于临床活动度的评估。临床多以临床活动度评分（clinical activity score,CAS）作为TAO活动度的评价标准,但有一定的局限性。CT成像眼外肌形态学的定量分析（眼外肌总横截面积/眼眶面积比值）结果与CAS评分呈正相关;通过眼外肌T2 mapping MRI定量分析提示眼外肌T2值与TAO免疫抑制疗效密切相关,有助于评估TAO免疫抑制疗效; 99mTc-DTPA 眼眶SPECT/CT采用图像融合技术,一次显像可获得功能信息与解剖信息,可作为CAS的有效补充。现代医学影像学特别是功能影像学对TAO活动度的评估具有较大的应用价值。（眼科,2018, 27： 321-324）     

生长抑素类似物眼眶显像在甲状腺相关性眼病诊疗中的应用

⁹⁹Tc^m-生长抑素类似物眼眶显像在甲状腺相关性眼病患者诊疗中发挥着重要作用,其不仅可用于判断患者眶周炎性活动度、早期诊断疾病、决定是否需要治疗以及选择治疗方案,同时也为该病评价疗效、判断预后和相关研究提供重要的客观依据。因此,⁹⁹Tc^m-生长抑素类似物眼眶显像在甲状腺相关性眼病中的应用有助于规范该病诊疗行为,有效提高诊疗水平和效率。（眼科, 2016, 25： 361-364）     

甲状腺相关眼病的放射治疗研究进展

甲状腺相关眼病(TAO)是成人最常见的眼眶疾病,发病率逐年增高,临床表现为眼球突出、眼睑退缩、眼球运动障碍及视力障碍,严重损害患者的生理和心理健康。西医常用糖皮质激素治疗、放射治疗和眼眶减压术等。其中,糖皮质激素治疗是针对中重度活动性TAO患者的一线治疗方案; 眼眶减压术主要针对严重眼球突出、眶压增高导致视神经受压损伤患者; 而对于不耐受或禁用糖皮质激素以及拒行眼眶减压术的TAO患者,可选用放射治疗。放射治疗通过发挥非特异性抗炎作用,能有效地改善患者临床症状,是治疗TAO的重要手段。随着计算机技术和医学影像学不断更新,放射治疗技术取得快速发展,三维适形放射治疗及调强放射治疗技术的出现使病灶精准定位成为可能。大量临床结果表明放射治疗TAO疗效好、不良反应可控。本文就放射治疗TAO的作用机制、技术特点、临床方案、放射剂量参数选择及并发症进行综述,以期为同行提供临床参考,制定个性化的TAO治疗方案。     

原发性眼眶脑膜瘤临床及影像诊断分析

目的：探讨原发性眼眶脑膜瘤的临床表现，影像学特征，诊断及治疗原则，方法：1979－1998年间诊治的原发性眼眶脑膜瘤115例进行回顾性分析，详细复习了全部病例的临床，病理资料及X线，B超，彩色多普勒超声，CT和（或）MRI的图像并进行比较，结果：原发性眼眶脑膜瘤可起源于视神经鞘和眶骨膜，多发生于中年女性，眼球突出，视神经萎缩，视力丧失和视睫状静脉为视神经鞘脑膜瘤的四联征，起源于眶骨膜的脑膜早期出现眼球突出和移位，视力减退出现较晚，X线，B超，CT和MRI有特征性表现，CT可以同时显示视神经增粗，眶内软组织肿块和眶骨改变，MRI可以更好地观察视神经管内及颅内蔓延状况，治疗原则主要为手术切除，结论：原发性眼眶脑膜瘤是种较为常见的眼眶肿瘤，影像学检查有助于诊断和鉴别诊断，一旦确诊，应早期手术治疗。     

眼眶减压术20眼临床分析

目的：探讨眼眶减压术对经保守治疗无效的甲状腺相关性眼病的临床疗效与合并症。方法：对12例20眼的术前临床表现、术后的疗效与并发症进行随访并统计。结果：三壁减压使眼球后退6－8mm,外下壁减压后退4－6mm,内下壁减压后退3－5mm。14／16眼（87．5％）角膜损害痊愈,2／16眼（12．5％）好转。17／20眼（85％）视力提高,3／20眼（15％）无改善。并发症包括2眼复视,5眼眶下神经损害,1眼眶继发出血。结论：眼眶减压术对保守治疗无效的甲状腺相关眼病是一种有效、安全、并发症少的治疗手段。可用于继发角膜损害,压迫视神经与要求美容 的病例。     

Reduced choroidal peripapillary capillaries in thyroid-associated ophthalmopathy with early stage of dysthyroid optic neuropathy

AIM: To investigate whether the subtle change of choroidal/retinal vessel densities and volumes in thyroid-associated ophthalmopathy (TAO) could be an early sign to detect dysthyroid optic neuropathy (DON). METHODS: This was a retrospective cross-sectional study, and a total of 98 eyes from 50 subjects were enrolled under certain criteria. Thirty-four eyes of normal controls and 64 eyes of TAO, including 39 eyes of DON and 25 eyes of TAO without DON, underwent optical coherence tomography angiography (OCTA) scanning. All the tested parameters of OCTA scanning including choroid radial peripapillary capillaries (RPC), retinal nerve fiber layer (RNFL), and macular ganglion cell complex (GCC) were compared among groups, and the correlation between OCTA parameters and visual function parameters was also investigated. RESULTS: Whole choroidal RPC was significantly reduced in DON (48.24%±0.4978%) compared to normal (50.33%±0.3173%) and TAO without DON (49.16%±0.5463%; P=0.0041). The reduction of whole choroidal RPC was also correlated with visual field (VF) defect in DON (r=0.5422, n=39). Although vision acuity and VF were improved in all the patients with DON after being treated with medical and surgical decompression, the reduction of RPC density were not reversed. CONCLUSION: There is a notable reduction in choroidal RPC in DON, which is correlated with VF defect. The reduction of RPC density could not be reversed immediately by medical and surgical decompression even when vision and VF were improved. These findings suggest that choroidal RPC could be a useful parameter to diagnose and monitor early stage of DON.     

Clinical features of dysthyroid optic neuropathy: a European Group on Graves' Orbitopathy (EUGOGO) survey

BACKGROUND: This study was performed to determine clinical features of dysthyroid optic neuropathy (DON) across Europe. METHODS: Forty seven patients with DON presented to seven European centres during one year. Local protocols for thyroid status, ophthalmic examination and further investigation were used. Each eye was classified as having definite, equivocal, or no DON. RESULTS: Graves' hyperthyroidism occurred in the majority; 20% had received radioiodine. Of 94 eyes, 55 had definite and 17 equivocal DON. Median Clinical Activity Score was 4/7 but 25% scored 3 or less, indicating severe inflammation was not essential. Best corrected visual acuity was 6/9 (Snellen) or worse in 75% of DON eyes. Colour vision was reduced in 33 eyes, of which all but one had DON. Half of the DON eyes had normal optic disc appearance. In DON eyes proptosis was > 21 mm (significant) in 66% and visual fields abnormal in 71%. Orbital imaging showed apical muscle crowding in 88% of DON patients. Optic nerve stretch and fat prolapse were infrequently reported. CONCLUSION: Patients with DON may not have severe proptosis and orbital inflammation. Optic disc swelling, impaired colour vision and radiological evidence of apical optic nerve compression are the most useful clinical features in this series.     

Imaging maculopathy in post-mortem human eyes

Age-related maculopathy (ARM) remains a poorly understood degeneration. To discover new pathways using contemporary genomics, proteomics, and immunohistochemistry, validate emerging animal models, and validate new imaging modalities, human tissues obtained from donor eyes will be essential to ARM research for the foreseeable future. Because fundus appearance is the clinical diagnostic lingua franca, laboratory investigators adapted these standards to the distinctive appearance of post-mortem tissues in order to identify and stage ARM in donor eyes. Post-mortem tissues offer unique advantages and limitations relative to pre-mortem tissues for imaging studies. One fellow eye can be used for imaging and the other for correlative laboratory studies, if some degree of disease stage asymmetry between eyes is acceptable. Histological verification is a necessary, albeit challenging, step in validating a grading system.     

Dysthyroid optic neuropathy (DON)

Dysthyroid Optic Neuropathy (DON) affects a small percentage of patients with Graves disease, but, when it occurs, it can cause significant and permanent loss of vision. DON is treatable if recognized early. Systemic steroids can be effective, but may cause side affects. Orbital injection of steroids may play a role in selected patients. Orbital radiation has a more permanent effect and has gained wide acceptance as a relatively non-invasive method of reversing DON. Surgery to decompress crowded orbits has been used for years and continues to be a viable approach for those patients with optic neuropathy, especially when there is significant proptosis. Optic nerve decompression can also be achieved through a transethmoidal approach.     

Dysthyroid optic neuropathy (DON)

Dysthyroid Optic Neuropathy (DON) affects a small percentage of patients with Graves disease, but, when it occurs, it can cause significant and permanent loss of vision. DON is treatable if recognized early. Systemic steroids can be effective, but may cause side affects. Orbital injection of steroids may play a role in selected patients. Orbital radiation has a more permanent effect and has gained wide acceptance as a relatively non-invasive method of reversing DON. Surgery to decompress crowded orbits has been used for years and continues to be a viable approach for those patients with optic neuropathy, especially when there is significant proptosis. Optic nerve decompression can also be achieved through a transethmoidal approach.     

Clinical profile and visual outcomes after treatment in patients with dysthyroid optic neuropathy

Purpose

To report the clinical data and visual outcomes after treatment of patients with dysthyroid optic neuropathy (DON).

Methods

We retrospectively reviewed the medical records and orbital images of 40 patients (65 eyes) with DON and analyzed the visual outcomes after treatment with intravenous steroids pulse therapy, radiotherapy and orbital decompression.

Results

The study included 21 men and 19 women, with 10 (25%) being diabetic patients. Visual field test results revealed defects in 88.7% of DON eyes; afferent pupillary defects in 63.2%; reduced color vision in 78.5%; and abnormal visual evoked potentials in 84%. Orbital imaging showed moderate to severe apical crowding in 95% of the orbits and intracranial fat prolapse in 24.2%. Median best corrected visual acuity improved from 0.4 to 1.0 after one year of treatment (p < 0.001). We noted more improvement in vision with the use of decompressive surgery than with non-surgical methods (p < 0.05). Recurrences occurred in 7 patients who had not received orbital radiotherapy.

Conclusions

Visual field defects and apical crowding seen on orbital imaging were the most sensitive indicators for the detection of DON. Treatment with intravenous steroids pulse therapy, radiotherapy and orbital decompression effectively improved visual outcomes in cases of DON.     

Changes in peripapillary blood vessel density in Graves’ orbitopathy after orbital decompression surgery as measured by optical coherence tomography angiography

The purpose is to evaluate the utility of optical coherence tomography (OCT) angiography in the evaluation of Graves’ orbitopathy (GO) and response to orbital decompression in patients with and without dysthyroid optic neuropathy (DON). This was a single-center, prospective case series in a cohort of 12 patients (24 orbits) with GO and ±DON, (6 orbits) who underwent bilateral orbital decompression. All patients underwent pre- and postoperative OCT angiography of the peripapillary area. Vessel density indices were calculated in a 4.5 mm × 4.5 mm ellipsoid centered on the optic disk using split-spectrum amplitude decorrelation angiography algorithm, producing the vessel density measurements. Mean change in vessel density indices was compared between pre- and postoperative sessions and between patients with and without DON. Patient 1, a 34-year-old male with GO and unilateral DON OD, showed a significant reduction in blood vessel density indices oculus dexter (OD) (DON eye) after decompression while a more modest reduction was found oculus sinister (OS) with the greatest change noted intrapapillary. Patient 2, a 50-year-old male with DON OU, showed worsening neuropathy following decompression OD that was confirmed by angiographic density indices. Patient 3, a 55-year-female with DON, showed a reduction in blood vessel density OD and increased density OS. Patients without DON showed overall less impressive changes in indices as compared to those with DON. Using OCT angiography, response to surgical treatment in GO orbits, more so in orbits with DON, can be demonstrated and quantified using vessel density indices with reproducibility.     

眼底自发荧光在急性后极部多发性鳞状色素上皮病变不同阶段的特征分析

目的　探讨眼底自发荧光在急性后极部多发性鳞状色素上皮病变（ａｃｕｔｅｐｏｓｔｅｒｉ-ｏｒｍｕｌｔｉｆｏｃａｌｐｌａｃｏｉｄｐｉｇｍｅｎｔｅｐｉｔｈｅｌｉｏｐａｔｈｙ,ＡＰＭＰＰＥ）中的影像学特征。方法　对２１眼急性期和１８眼恢复期ＡＰＭＰＰＥ患者行眼底自发荧光检查,对比眼底彩色照像及眼底荧光血管造影结果,观察不同病变阶段的影像学特征,分析该病的发展转归。结果　急性期眼底自发荧光可见与眼底彩色照像及眼底荧光血管造影一致的高自发荧光区,高荧光边缘可见一低荧光区域。部分眼底彩色照象及眼底荧光血管造影已显示的病灶,在自发荧光成像上尚未显现。恢复期患者眼底自发荧光可见与眼底彩色照像及眼底荧光血管造影相一致的完全低荧光区,如尚存部分未完全死亡的视网膜色素上皮细胞,则在部分区域可见强荧光。结论　ＡＰＭＰＰＥ患者可根据自发荧光的强弱判断病变阶段、病变进程情况,评估视网膜色素上皮细胞的功能。     

糖尿病性视神经病变的OCT图像特点分析

目的：回顾分析糖尿病性视神经病变( diabetic optic neuropathy, DON )的相干光断层成像( optical coherence tomography,OCT)的特点。
　　方法：回顾性系列病例研究。选择2013-12/2015-10西安交通大学医学院第二附属医院眼科门诊和内分泌科会诊期间诊断为2型糖尿病且伴有眼底病变的患者175例350眼的临床资料,记录患者的全身检查情况和疾病史,阅读所有患者的彩色眼底照相、荧光素眼底血管造影( fluorescein fundus angiography,FFA)、OCT的影像结果,并进行分析统计。
　　结果：通过FFA 检查视乳头具有异常荧光表现,确定有DON的有49例90眼,占25.7%。 OCT结果显示DON 90眼中15眼(16.7%)表现为视神经形态大致正常;20眼(22.2%)表现为视杯凹陷变小或消失,筛板前组织肿胀,同时伴有盘周神经纤维层水肿;26眼(28.9%)表现为视杯深陷,杯盘比变大;18眼(20.0%)表现为视盘内或视盘表面组织增生;11眼(12.3%)玻璃体视乳头牵拉,视盘边缘抬高。在FFA中有相同荧光表现的DON患眼,在OCT检查可表现出不同的组织形态。
　　结论：FFA从视神经的血循环状态变化定义DON,而OCT可以发现FFA所不能显示的视神经组织形态的变化,从而更清晰视神经病变的位置和原因,为治疗提供依据。OCT无创、快捷、费用低、可重复性强等优点有利于DON患者的复查及治疗效果追踪。     

Contrast sensitivity and the diagnosis dysthyroid optic neuropathy

Contrast sensitivity function (CSF) was investigated in 19 patients (34 eyes) with clinical signs and symptoms of dysthyroid optic neuropathy (DON). CSF was disturbed in 33 eyes and was shown to improve after orbital decompression. These results indicate that the CSF may be a useful supplementary test of visual function in patients with DON.Abbreviations CSF contrast sensitivity function - DON dysthyroid optic neuropathy - RE right eye - LE left eye - c circles - deg degrees This study was presented at the annual meeting of the Dutch Ophthalmological Society, Dronten, 13–16 February 1990.