30例Graves眼病联合治疗临床分析

GO（又名甲状腺相关性眼病），是一种与Graves病既有关联又独立的器官特异性自身免疫性疾病，Graves病伴发浸润性突眼一直是内分泌疾病治疗中较棘手的问题。有关突眼的发病机制研究近年虽有进展，但是目前尚未阐明，因此治疗方面针对性较差，效果不太理想。作通过对Graves眼病患在抗甲状腺药物基础上联合球后放疗、糖皮质激素、免疫抑制剂治疗，取得了较满意疗效，现报道如下。     

局部放疗与球后注射治疗Graves眼病的临床疗效观察

【目的】寻找治疗Graves眼病较为有效的方法 ,研究联合应用眶内局部放疗与长效糖皮质激素球后注射治疗Graves眼病的疗效。【方法】随机选取在本科住院治疗的Graves眼病患者 5 2例 90眼 ,根据治疗方法不同随机分为联合治疗组 (糖皮质激素球后注射治疗 +眶内放疗 ) 2 6例 4 6眼 ,对照组 (糖皮质激素球后注射治疗 ) 2 6例 4 4眼。治疗前后分别测量两组患者患眼的眼球突出度与睑裂宽度并观察症状及眼征情况。【结果】对照组治疗前后眼球突出度差异有显著性 (P <0 .0 5 ) ;睑裂宽度差异无显著性 (P >0 .0 5 )。联合治疗组治疗前后眼球突出度及睑裂宽度差异均有显著性 (均P <0 .0 5 )。同时 ,联合治疗组眼球突出度及睑裂宽度下降均较对照组明显 ,两组比较差异均有显著性 (均P <0 .0 5 )。联合治疗组症状改善率为 96 .2 % ,对照组症状改善率为 84 .6 %。【结论】联合应用眶内局部放疗与长效糖皮质激素球后注射治疗Graves眼病是一种较为有效的治疗方案 ,其治疗效果优于单独使用糖皮质激素。     

强的松和环磷酰胺冲击治疗浸润性突眼临床观察

浸润性突眼，即Graves眼病（Graves ophthalmopathy，GO），又称恶性突眼，是一种难治性内分泌疾病，可与甲状腺功能亢进共存，也可以单独存在。为浸润性损害累及眼眶内容物所致。眼部征状较重，多数预后较差。近年来，随着显像技术的发展，如眼眶CT扫描、眼眶超声检查等，发现本病发病率较高。其发病机制尚不甚清楚，但已明确为自身免疫性疾病。目前对本病的治疗尚不满意，我院采用大剂量激素联合环磷酰胺冲击治疗，收到较好疗效，现报道如下。     

球后注射治疗Graves眼病的护理

突眼性甲状腺肿（Graves）眼病为眼眶常见病，居成人眼眶病的首位。目前，治疗方法众多，主要是药物、手术治疗、眼局部治疗、免疫抑制剂治疗及放疗。球后注射是局部给药的重要方法和途径，具有疗效快、给药准确，同时又可避免全身用药不良反应等优点。我科自2004年以来，对783例Graves眼病患者施行球后注射治疗。现将护理操作及体会介绍如下。     

甲状腺相关眼病病人球后注射法探讨

甲状腺相关眼病是眼眶疾病中最常见的单、双眼球突出的原因。据报道，在成人眼眶疾病中，甲状腺相关眼病国内外发病率均占第一位，约占20％。甲状腺相关眼病的治疗十分困难，传统治疗对于“恶性突眼”采用糖皮质激素冲击，造成严重的全身毒副反应，而局部球后注射曲安奈德治疗甲状腺相关眼病是安全有效的。但由于该病眼部症状以眼外肌肥大、眼球突出、眼眶内压力增高导致突眼为特征，此种治疗方法有可能引起视网膜中央动脉栓塞、眼压升高、刺破眼球和球后出血等并发症，处理不及时将导致严重不良反应，而针对该病特点进行球后注射技术目前没有文献报道，我们在临床工作中通过实践，研究总结出注射方法。现介绍如下。     

激素冲击疗法联合眼眶放射治疗对甲状腺相关眼病患者眼表症状和视力水平的影响

目的:探讨激素冲击疗法联合眼眶放射治疗对甲状腺相关眼病患者眼表症状和视力水平的影响。方法:选择2021年2月至2022年7月我院收治的124例甲状腺相关眼病患者为研究对象,随机分组为激素联合放疗组和单纯放疗组,单纯放疗组给予眼眶放射治疗,激素联合放疗组在单纯放疗组基础上联合激素冲击疗法(甲泼尼龙+泼尼松),比较两组患者视力、视野、眼压、眼球突出度。结果:治疗后,两组患者视野水平、眼压值、眼球突出度均较单纯放疗组明显改善,其中激素联合放疗组患者视野缺失(-1.16±0.37)dB,明显少于单纯放疗组(P<0.05),眼压水平(19.37±1.54)mmHg,明显低于单纯放疗组(P<0.05),眼球突出度(17.83±0.53)mm,明显小于单纯放疗组(P<0.05);两组患者治疗后的视力水平均较治疗前明显改善,其中激素联合放疗组治疗后1个月、6个月的视力水平均优于单纯放疗组(P<0.05)。结论:激素冲击疗法联合眼眶放射治疗甲状腺相关眼病患者在提升视力水平、降低眼压、改善眼表症状方面的效果显著,值得推广。     

三壁微创眼眶减压术治疗Graves眼病的护理

<正>眼眶减压手术治疗Graves眼病已有100年历史。随着手术技术和适应证的不断进展,被越来越多的患者所接受。我院于2005年9月至2007年3月对6例10眼Graves眼病重度突眼患者采取三壁微创眼眶减压术联合短期甲基强的松龙冲击治疗,配合良好的术前、术后护理,取得了较满意的疗效,现将护理体会报告如下。1临     

CT在Graves病眼眶改变中的诊断价值

目的:研究Graves病(GD)眼眶改变的CT扫描表现,探讨CT检查在GD临床诊断和治疗中的应用价值。方法:对68例经临床和实验室检查诊断为GD患者的136只眼眶进行CT扫描检查,并对结果进行统计学分析。结果:GD患者常表现为眼外肌增粗,其眼外肌大小与正常人比较差异有统计学意义(均P<0.05),其中内直肌最常受累(67.6%),其次为下直肌(58.8%)、上直肌(45.6%),最后是外直肌(30.9%)。在136只眼眶中发现眼球突出118只眼,其中I度突眼97只眼,Ⅱ度突眼21只眼,突眼发现率86.8%(临床上突眼诊断率66.9%)。GD患者还存在眼外肌密度变化等影像学改变。结论:眼眶CT扫描可作为GD患者的常规检查方法,指导Graves眼病(GO)的诊断和治疗。     

己酮可可碱联合强的松治疗Graves眼病的疗效观察

目的：观察己酮可可碱联合强的松治疗Graves眼病的疗效。方法：将60例Graves眼病患者随机分成两组。对照组给予抗甲状腺药物及强的松;治疗组增用己酮可可碱。结果：两组总有效率分别为80.65%、44.83%（P〈0.01）;治疗组突眼度及血流变学指标改善明显。结论：己酮可可碱联合强的松治疗Graves眼病可提高临床疗效,改善血流变学指标。     

球后注射糖皮质激素治疗甲状腺相关眼病的Meta分析

目的系统评价球后注射糖皮质激素治疗甲状腺相关眼病的临床效果。方法计算机检索CochraneLibrary（2010年第1期）、EBMReviews、PubMed和中国生物医学文献数据库。检索时间为建库至2010年4月。全面收集球后注射糖皮质激素治疗甲状腺相关眼病的随机对照试验（RCT）,评价纳入研究质量,提取有效数据,采用RevMan4.2.8软件进行Meta分析。结果共纳入7个RCT,共398例患者。按测量指标和干预措施进行亚组分析。Meta分析结果显示,总有效率比较,球后注射优于空白对照组,差异有统计学意义[RR=1.35,95%CI（1.10,1.65）,P=0.004],球后注射与口服激素间差异无统计学意义[RR=1.15,95%CI（0.93,1.42）,P=0.20],球后注射组与球后注射联合放疗组差异有统计学意义[RR=0.85,95%CI（0.72,1.00）,P=0.04]。球后注射组3例患者出现眶内出血和2例患者出现软组织加重的局部并发症,未出现体重加重及柯兴综合征等全身并发症。结论现有临床研究证据显示,球后注射糖皮质激素是治疗甲状腺相关眼病的有效治疗方案,可避免全身用药的副作用。联合球后放疗可提高疗效。     

生长抑素类似物治疗Gravesl眼病有效性的Meta分析

目的系统评价生长抑素类似物治疗Graves眼病（GO）的有效性。方法计算机检索PubMed、EMbase、The Cochrane Library、WanFang Data、CNKI、VIP和CBM中关于生长抑素类似物治疗Graves眼病的随机对照试验（RCT）,检索时间截至2012年3月,并追溯纳入文献的参考文献。由2位研究者按照纳入标准筛选文献、提取资料和评价纳入研究的方法学质量后,采用RevMan5．0软件进行Meta分析。结果最终纳入5个RCT,共210例患者。Meta分析结果显示：生长抑素类似物治疗GO可降低临床活动性评分[MD=0．58,95％CI（0．02,1．13）,P=0．04],但尚不能证实可降低突眼度（mm）[MD=0．21,95％CI（-0．14,0．56）,P=0．24];对复视程度、球后体积、眼压、视力及眼球活动受限未显示出明显疗效;目前证据尚不能说明生长抑素类似物治疗GO有效[OR=I．32,95％CI（0．45,3．9）,P=0．61].结论生长抑素类似物治疗GO可降低患者的临床活动性评分,但未能明显降低突眼度,目前证据尚不能证实生长抑素类似物治疗GO有效。受纳入研究的质量和数量限制,上述结论尚需开展更多高质量RCT加以验证。     

Effectiveness of steroid therapy in acute exacerbations of asthma: a meta-analysis.

The objective of this study was to determine the effect of steroid therapy on pulmonary function, admission rates, and relapse rates in patients presenting with acute exacerbations of asthma. Computerized MEDLINE and SCIENCE CITATION searches were combined with review of reference lists from book chapters and articles to identify published randomized trials on steroid interventions. Over 700 articles were reviewed by two independent reviewers who identified 30 relevant randomized controlled trials for analysis. Study validity was independently assessed by two reviewers and information regarding populations, interventions, and outcomes was abstracted. Binary outcomes were combined and reported as odds ratios (OR), using the Mantel-Haenszel method. Individual and pooled effect sizes (ES) were determined for pulmonary function data. The authors found that the use of steroids early in the treatment of asthmatic exacerbations reduces admissions in adults (common OR 0.47; 95% confidence interval (CI) 0.27, 0.79) and children (OR 0.06-0.42). They found steroids effective in preventing relapse in the outpatient treatment of asthmatic exacerbations (OR 0.15; CI 0.05, 0.44). Oral and intravenous steroids appear to have equivalent effects on pulmonary function in acute exacerbations (ES -0.07; CI -0.39, 0.25). The authors conclude that overall, steroid therapy provides important benefits to patients presenting to emergency departments with acute exacerbations of asthma. Further research into dosage, alternative routes of administration, and alternative outcome measures is needed.     

Comparison of intravenous methylprednisolone therapy vs. oral methylprednisolone therapy in patients with Graves' ophthalmopathy

A prospective, randomised and single blind clinical trial was designed to compare intravenous methylprednisolone pulse (IVGC) with oral methylprednisolone (OGC) monotherapy in terms of effectiveness and tolerability in Graves' ophthalmopathy (GO). Fifty-two consecutive patients with untreated, moderately severe and active GO were randomly treated with either IVGC or OGC therapy for 12 weeks. IVGC therapy achieved a more rapid and significant improvement than OGC therapy according to clinical activity score (p < 0.01), proptosis (p < 0.038), lid width (p < 0.0001), extraocular muscle changes (p < 0.02), optic neuropathy. (p < 0.001), intraocular pressure (p < 0.04), visual acuity (p < 0.03), quality of life (p < 0.0001) and treatment response (p < 0.001). Diplopia was significantly improved in two groups but there was no difference between them (p < 0.6). Heavy smokers indicated alteration of ophthalmic signs with increased thyroid stimulating hormone (TSH)-receptor antibody during the therapy. In conclusion, IVGC therapy was more effective and better tolerated than OGC therapy in the management of GO.     

甲状腺相关性眼病行内镜下内侧壁眶减压联合脂肪减压术后眼眶各容积参数的变化

目的初步观察甲状腺相关性眼病(TAO)行内镜下内侧壁眶减压联合脂肪减压术后眼眶各容积参数的变化。方法回顾分析2014年9月-2015年8月于温州医科大学附属眼视光医院由于眼球突出影响外观而行内镜下内侧壁眶减压联合脂肪减压术的TAO患者1 1例(20眼),所有患者确诊为非组织活动期至少6个月,均因眼球突出影响外观而行手术治疗。所有患者术前和术后第3个月行高分辨率CT(HRCT)。运用眼眶CT结合计算机辅助测量软件测量眼球突出度,分析TAO手术前后眼眶各容积参数变化情况,并分析与眼球回退值之间的关系。结果术后眼球突出度较术前有明显降低;手术后内直肌容积(MMV)、球后脂肪容积(FV)、眼眶容积(OV)较术前有增加;手术前后眼外肌容积的变化值(?MV)与眼球回退值呈负性相关,眼眶容积变化值(?OV)与眼球回退值也呈负性相关。结论术后3个月内直肌的增粗,可能与手术干扰、术中去除内侧壁有关。眼外肌体积变化和眼眶容积变化与眼球突出度回退之间存在显著的负相关性。     

免疫印迹检测抗眼肌抗体

用含ＴｒｉｔｏｎＸ－１００及脱氧胆酸钠的ＴＤＯＣ缓冲液自牛眼肌提取了眼肌细胞膜抗原，建立了抗眼肌多肽抗体的免疫印迹检测法。     

Contact B-scan echographic diagnosis of ophthalmopathic graves' disease

Ophthalmopathic Graves' disease (endocrine ophthalmopathy) is difficult to diagnose with certainty in the absence of confirmatory laboratory studies. In 11 of 15 patients with proven Graves' ophthalmopathy who were studied with contact B-scan ultra-sonography, distinct evidence of orbital edema was demonstrated. Since these abnormalities were not encountered in any of eight patients with tumorous invasion of the rbit causing proptosis, or in any of 50 patients studied for intraocular pathology, it is concluded that contact B-scan echography is a valuable diagnostic tool and should be utilized early in the study of all patients with orbital disease.     

Graves眼病的诊治

Graves眼病(GO)是Graves病最常见的一种甲状腺腺外表现,其发病机制涉及遗传、环境和自身免疫紊乱等多种因素,临床表现复杂多样,只有对GO的活动性和严重程度做出准确评估,才能选择恰当的治疗方案。活动期中、重度GO最有效的治疗方法是糖皮质激素和眶部放射,近年来也发展了一些新的治疗方法,疗效有待于进一步证实。     

The relationship between anti-human eye muscle antibodies and thyroid function, anti-TSH receptor antibodies and eye symptoms in Graves' ophthalmopathy.

Circulating IgG, IgA, and IgM antibodies to human eye muscle cytosol antigens were studied in 60 patients with Graves' ophthalmopathy using the indirect ELISA method. There was a significant difference in the levels of both IgG and IgA antibodies between the patients with Graves' ophthalmopathy and a control group (p < 0.001). IgA antibodies to eye muscle cytosol antigens were raised in 20 out of 29 patients with proptosis (class 3 ophthalmopathy), in comparison with 31 patients out of the total group of 60 with Graves' ophthalmopathy (p < 0.02). Anti-TSH receptor antibodies (TRAK) were not present in over half of the 31 patients with raised IgA antibodies to eye muscle antigens. However, a significant difference was found between the levels of IgG and IgA antibodies in the TRAK-negative patients (p < 0.05). These findings suggests that both IgG and IgA antibodies to eye muscle antigens might be important in the development of ophthalmopathy.     

Current understanding of pathogenesis of Graves ophthalmopathy

Graves ophthalmopathy most frequently develops in a patient suffering from Graves disease in which autoantibodies to a target antigen, thyrotropin receptor, activate the autoantigen leading to hyperthyroidism. It is well known that in Graves ophthalmopathy inflammatory cells infiltrate and hydrophobic glycosaminoglycan accumulates in the retro -occular tissues. However, in contrast to Graves disease, little has been known as to how this eye disease develops. Here we review recent advance in understanding of pathogenesis of Graves ophthalmopathy.