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。     

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。     

视神经减压术治疗创伤性视神经病的疗效观察

目的 观察视神经减压术治疗创伤性视神经病的临床疗效.方法 30例创伤性视神经病患者,分别采用鼻外径路或经鼻内镜筛蝶窦径路施行视神经减压术,观察手术治疗的临床效果.结果 总有效率56.67%.术前无光感的16例中,6例术后视力显示一定程度的改善;术前有残余视力的14例中,11例的术后视力均有不同程度的提高.无1例发生严重并发症.结论 视神经减压术对创伤性视神经病导致的视力障碍,无论伤后时间长短和是否具有残余视力,均具有确切疗效.     

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。     

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。     

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。     

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.     

影像导航下视神经减压术治疗外伤性视神经病

目的探讨影像导航下视神经减压术治疗外伤性视神经病（TON）的临床特点和预后影响因素。方法回顾性分析自2015年1月—2018年12月山西医科大学第二医院收治的20例TON患者的临床资料。通过单因素分析和非条件Logisitic回归分析评估不同因素对TON治疗效果的影响。结果术后随访3个月至1年,总有效率为60.0％（12/20）,其中术前有光感及以上者有效率为100.0％（6/6）,无光感者有效率为42.9％（6/14）。受伤1周内手术者,有效率75.0％（9/12）。术前CT显示视神经管骨折者,有效率为22.2％（2/9）。单因素与多因素结果均显示：术前视力、CT显示视神经管骨折是患者手术预后的影响因素。结论鼻内镜下视神经减压术是治疗TON的有效手段。术前有光感及以上是视力改善的保护性因素,术前CT显示视神经管骨折是视力无改善的危险性因素。对于伴有复杂颅面部外伤的患者,影像导航的应用可以达到精准定位,有效减压的目的,从而提高手术疗效,值得推广。     

Trans-ethmoidal optic nerve decompression

Blunt head injury frequently results in visual impairment, the optimal treatment of which is still debated. Over a 5-year-period (1987–1991) 111 patients with indirect optic nerve injury resulting from closed head trauma have been treated. In each case loss of vision was the only neurological deficit. In group A, 66 patients were initially treated with large doses of prednisolone (80 mg/day) for 3 weeks. Twenty-seven patients improved on steroids alone. In the remaining 39 patients in whom either unsatisfactory or no improvement occurred a transethmoidal optic nerve decompression was performed. Twenty-two patients in the latter group improved, thus yielding an overall improvement rate of 74.2% in group A. Group B (control), in which 45 patients were treated with prednisolone only (80 mg/day for 3 weeks), had an overall improvement rate of 51% (23 patients). The study reveals that while nearly half of such patients can improve on steroids alone, optic nerve decompression significantly improves recovery rates in patients where conservative treatment is unsatisfactory (P < 0.05). Total loss of vision not responding to steroids, absence of waveform on visual evoked response, and presence of an optic canal fracture indicate a poor prognosis.     

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,所有患者随访6个月,14例术前无光感,术后有效6例,有效率42.9%。7例术前有残余光感,术后有效5例,有效率71.4%。伤后7 d内手术13例,术后有效9例,有效率69.2%。伤后7 d后手术8例,术后有效2例,有效率25.0%。结论 经鼻内镜视神经减压是治疗TON的有效方式,患者术前是否有残余光感及手术时机选择是否在7 d内对预后至关重要。     

外伤性视神经损伤的临床处理

目的 :观察经鼻外筛蝶窦径路行视神经减压术辅助药物治疗对外伤性视神经损伤的疗效。方法 :14例外伤性视神经损伤患者经鼻外筛蝶窦径路行视神经减压术的同时辅以大剂量激素及神经营养药物治疗。结果 :总有效率为 5 7.14% ,术中、术后无任何严重并发症 ;其中 2例伤后 8、11d手术 ,术后 6个月仍无光感。结论 :鼻外筛蝶窦径路行视神经减压术损伤较小 ,术野暴露充分 ,简易安全 ;同时辅以药物治疗 ,更有利于神经功能恢复。综合性治疗对外伤性失明患者是一种较好的措施。     

视神经外伤经筛、蝶窦径路减压术治疗(附35例报告)

为了解经筛，蝶窦径路行视神经减压术对外伤视神经损伤治疗的有效性及手术时机的选择作回顾性研究。对４１你外伤性视神经损伤患者中的３５列行经筛，蝶窦径路减压术，另６例应用大剂量皮质激素保守治疗。结果手术后中１３２例视力得到改善，保守治疗者中１例视力改善。１２例治疗前有残余和的患者，８例接受手术治疗，其中７例视力理以改善；４例接受保守治疗者１，例视保守治疗者，视力均未得到改善。结论：经筛蝶窦径路视神经减压     

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.     

外伤性视神经损伤的手术时机与疗效的相关性研究

目的 :探讨外伤性视神经损伤的手术时机与疗效的关系。方法 :经鼻外眶筛蝶窦进路显微视神经管减压术 9例 ;经鼻内窥镜筛蝶窦进路行视神经管减压术 14例 ,辅以大剂量皮质类固醇激素、能量合剂和神经营养药物。结果 :2 3例中有效 13例 ,视力平均提高 0 .2 33,无效 10例 ,有效率为 5 6 .5 %。 13例有效患者 ,其外伤至手术时间平均为 (2 .91± 1.87) d;10例无效患者 ,其外伤至手术时间平均为 (12 .90± 16 .77) d,两者相比较 ,其差异有极显著性意义 (P <0 .0 1)。8例外伤后眼球活动受限的患者 ,其中 7例恢复正常。结论 :外伤性视神经损伤在经过大剂量类固醇激素等治疗 48h无效者 ,应立即进行视神经管减压术 ,手术时机最好在外伤后 7d内进行。     

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。     

Optic nerve decompression in the comatose and conscious patients after trauma

OBJECTIVE: To investigate the efficacy of early optic nerve decompression in comatose and conscious patients with indirect traumatic optic neuropathy. STUDY DESIGN: Retrospective analysis of 65 optic nerve decompressions. METHODS: The total collective of optic nerve decompressions comprised 65 patients treated within the period between February 1987 and December 1998. Thirteen of these 65 patients (average age, 32 y) were comatose and required critical care treatment, so visual acuity could not be measured. The indication for surgical decompression in all patients was based on the ophthalmological examination and the finding on computed tomography (CT) scan of a lesion inside the optic nerve canal or the orbit apex, respectively. RESULTS: In the comatose patients the time interval between trauma and surgery was 16.1+/-12.1 hours (mean +/- standard deviation). During the subsequent postoperative examinations (on average, 12.3 mo postoperatively) five patients showed a normal visual acuity (20/20), two patients a visual acuity of 20/30 and 20/50, and one a visual acuity of 20/200. Three patients (three eyes) remained amaurotic. Two patients died of the general and severe consequences of injury. The beneficial visual acuity results achieved within the group of comatose patients were equivalent to those achieved within the group of patients who were conscious during the preoperative examination. The success rate, defined as an improvement of three lines with a final visual acuity of at least 20/1000, was 57.7% versus 61.5%. CONCLUSION: The results confirm our concept of early decompression of the optic nerve, based on close interdisciplinary cooperation and the ophthalmological findings.     

影像导航下经鼻内镜视神经减压治疗伴脑脊液鼻漏的创伤性视神经病

目的:探讨影像导航系统在伴有脑脊液鼻漏的创伤性视神经病患者手术治疗中的应用。方法:回顾性分析2006-06-2010-01期间收治的12例伴脑脊液鼻漏的创伤性视神经病患者,均在影像导航下经鼻内镜行视神经减压术,并同时行脑脊液鼻漏修补术。结果:随访3个月～1年,脑脊液鼻漏全部修补成功,患者视力恢复到0.3～0.6者1例,0.1～0.3者2例,0.1以下者1例,手动1例,恢复光感2例,总有效率为58.33%。结论:鼻内镜和影像导航系统的结合应用使手术视野开阔、定位精确并增加了安全性,尤其在局部解剖结构因外伤而导致毗邻关系改变的情况下,可有效减小创伤,提高安全性,是一种安全有效的治疗方法。     

眶-筛-蝶联合径路视神经减压术的临床应用

目的 :探讨提高视神经管内段损伤疗效的方法。方法 :采用眶 筛 蝶联合径路对 5 2例视神经管内段损伤进行减压术治疗 ,全程松解视神经。结果 :术后视力得到不同程度恢复者 2 2例 ,视力改善率为 42 .3%。其中继发性视力损伤 2 3例 ,视力提高者占 73.9% ;原发性视力损伤 2 9例 ,视力提高者占 17.2 %。随访 6个月 ,视力恢复至 0 .0 5～ 0 .6。结论 :眶 筛 蝶联合径路视神经减压术进路短 ,视野宽 ,便于操作 ;且解剖标志清楚 ,易定位 ,更安全 ,更适合筛、蝶窦发育不良 ,骨质增生者。     

Optic nerve decompression in trauma and tumor patients

Optic nerve decompression is a procedure that is now receiving increasing clinical attention. However, there are currently no standardized treatment protocols in the therapy of traumatic or pressure insults to the nerve. The present retrospective study was designed to report our experience with microscopic endonasal transethmoid-sphenoid optic nerve decompression in 24 unilateral trauma cases and 11 unilateral skull base tumor patients. In general preoperative visual acuities in the trauma patients were worse than in the tumor patients. Following surgery, 9 of 11 tumor patients (82%) had at least some improvement of their vision, including 5 complete recoveries. In the group with traumatic visual impairment, 16 of the patients had no light perception preoperatively. Postoperatively, 13 patients (54%) had at least some improvement, with 4 patients regaining normal or near normal vision. Compared to other techniques and approaches, our technique is a minimally invasive procedure for optic nerve decompression, reducing unnecessary operative trauma to nasal structures, skin incisions or even craniotomy and frontal lobe retraction. Received: 23 June 1998 / Accepted: 4 December 1998