Graves眼病部分免疫抑制剂疗效探讨

目的　对比几种免疫抑制剂对Graves眼病的疗效 ,旨在寻求免疫治疗的有效手段。方法　Graves眼病 75例 ,A组 31例 ,采用泼尼松 (16例 ,其中完成 13例 )或雷公藤多甙 (TW ,15例 )治疗 ;B组 2 3例 ,采用环孢素A(CsA ,11例 )或霉酚酸酯 (MMF ,12例 )治疗 ,疗程 12周 ;对照组 2 1例 ,仅给抗甲状腺药治疗并调节甲状腺功能。疗效判断采用改进的Given Wilson积分指数系统 ,积分下降或上升≥ 3分为好转或恶化 ,<3分为无变化。结果　 12周末 ,泼尼松组 13例中 7例好转 ,6例无效 ;TW组15例中 10例好转 ,5例无变化 ;CsA组 11例中 5例好转 ,6例无效 ;MMF组 12例中 11例好转 ,1例无变化 ;对照组 2 1例中 4例好转 ,5例恶化 ,12例无效。MMF好转率高于CsA(P <0 0 5 ) ;TW与泼尼松比较差异无显著性 (P >0 0 5 )。各治疗组 12周末眼病分值均有下降 (P <0 0 1) ,下降幅度大小依次为MMF、TW、泼尼松和CsA组。结论　MMF用于治疗Graves眼病疗效优于CsA ,且较低剂量应用副作用不多 ;较小剂量的TW治疗Graves眼病疗效与泼尼松相仿 ,但可能副作用较少。     

Orbital Decompression for the Treatment of Spontaneous Globe Luxations

Aims: To describe the results of orbital decompression in patients with spontaneous globe luxations and to evaluate predisposing factors for this condition.

Methods: The clinical records of patients who underwent orbital decompression for the treatment of spontaneous globe luxations between 2010 and 2013 were reviewed. Data collected were age, gender, predisposing factors, preoperative and postoperative exophthalmometry, duration of follow-up, presence of diplopia before and after surgery and intra- and postoperative complications.

Results: Seven patients underwent orbital decompression after spontaneous globe luxation during the study period. Six patients underwent bilateral decompression. Two patients underwent a three-wall decompression, four of them medial and lateral decompression and one patient medial decompression. The predisposing factors for globe luxation were Graves’ orbitopathy, malar hypoplasia, high myopia, floppy eyelid syndrome and orbital fat hypertrophy in the context of obesity. After orbital decompression, none of the patients reported new globe luxations. No intraoperative complications were observed. None of the patients developed de novo diplopia.

Discussion: Orbital decompression is an effective method for the prevention of new episodes in patients with spontaneous globe luxations. It has good aesthetic and functional results and addresses the exophthalmos present in most cases.     

以突眼为表现的眼部血管病——颈动脉海绵窦瘘的介入治疗

目的探讨颈动脉海绵窦瘘眼部表现特点、影像学检查及介入治疗方法。 方法回顾分析5年中18例首诊于我院眼科的颈动脉海绵窦瘘者的眼部症状及体征、影像学检查、治疗方法等。18例患者均行介入手术治疗,其中应用可解脱球囊封堵瘘口12例,应用弹簧圈+Onyx胶封堵瘘口3例,覆膜支架隔绝瘘口3例。 结果所有病例中最常见的眼部表现为搏动性眼球突出、球结膜充血水肿、眼球运动障碍等。头颅或眼部CT平扫检查所有病例均显示患侧眼球突出,眼上静脉增粗;全部患者均行数字减影血管造影检查明确诊断。本组18例（20眼）均行介入手术治疗,其中应用可解脱球囊封堵瘘口12例（14眼）,结果10例（12眼）瘘口完全闭塞,发生并发症2例,无严重并发症或死亡病例。应用弹簧圈+Onyx胶封堵瘘口3例（3眼）、覆膜支架隔绝瘘口3例（3眼）,瘘口均完全闭塞,无并发症或死亡病例。全部手术患者眼部症状和体征均得到明显改善。随访时间（12±3.4）个月,无复发病例,颈动脉覆膜支架内未发生狭窄及闭塞。 结论对于以突眼及其他相关症状就诊于眼科的患者,应考虑颈动脉海绵窦瘘的可能,血管造影是该病诊断的金标准,介入手术治疗对颈动脉海绵窦瘘是安全有效的。     

糖皮质激素对Graves眼病和Th1/Th2细胞因子的影响

目的探讨糖皮质激素对Graves眼病（GO）突眼的疗效以及对Th1／Th2细胞因子的影响。方法45例GO分为4组：B组抗甲状腺药物治疗；C组同时口服强的松；D组：C组＋球后注射地塞米松；E组：C组＋甲状腺注射地塞米松和奥曲肽。结果GO患者血清Th1和Th2细胞因子明显升高，糖皮质激素治疗后下降，C组突眼的疗效为63．6％，D组和E组有效率分别为78．6％和80％。结论糖皮质激素对突眼的疗效是肯定的，可能是通过调节细胞因子的水平而发挥作用，球后或甲状腺注射能提高疗效。     

鼻窦肿瘤的眼部表现分析

为了早期诊断和治疗以眼部症状就诊的鼻窦肿瘤患者，分析６０例鼻窦肿瘤的眼部症状，表现为眼球突出、眼球运动障碍、复视、视力下降或丧失、上睑下垂等。其中４２例首诊于眼科。所有病例均经ＣＴ扫描和病理病检查证实。４８例采用手术治疗，３２例眼部症状改善。结果提示鼻窦肿瘤易出现眼部症状的原因，主要是由于鼻窦与眶壁、鼻窦与视神经管之间密切的解剖学关系。ＣＴ扫描有助于该病的早期诊断。     

眼球突出度的CT测量及其临床意义

目的探讨眼眶CT眼球突出度测量方法与Hertel眼球突出计测量方法之间的关系,及其对眼眶病患者眼球突出诊断中的意义。方法对42例临床资料完整的眼眶病患者的眼球突出度进行回顾性分析。所有病例均进行RB线横轴位2mm薄层螺旋CT扫描。选取眼球最大径层面,在图像工作站上测量其眼球突出度(CT眼突度)。与其临床上采用Hertel眼球突出计测量所得眼球突出度(Hertel眼突度)进行统计学分析。结果两种方法测量眼突度有差异,CT眼突度显著高于Hertel眼突度(P<0.001);两种方法之间有直线相关关系(r=0.864,P<0.001);而两种方法对两眼眼突差的测量,差异无统计学意义(P>0.05)。结论Hertel眼球突出计在测量眼眶病双眼眼突差中常规使用,具有简便可靠的特点。而眼眶CT为眼球突出的测量提供了更直观、准确的数据,有一定的临床价值,可以作为异常眼球突出更精确测量的补充参数,尤其客观地反映了异常眼球突出的程度及提供了治疗前后的影像。     

突眼和颅面部发育不良的外科矫治术

目的　分析手术治疗颅面发育不良所致突眼症的效果和并发症。方法　针对不同年龄的患者 ,选用 3种不同的手术方法 :1～ 3岁者 ,选用全额骨块截骨和额眶带前移手术 ;4～ 15岁者 ,选用LeFortⅢ型颅面部截骨和骨牵拉成骨术 ;16岁以上患者 ,选用LeFortⅢ型颅面部截骨前移术 ,于截骨当时即期前移颅骨或中面部骨架。结果　 18例患者均取得了良好的治疗效果 ,眼球突出度平均减少 7 7mm ,前颅底前后向深度平均增加 8 2mm ,眼眶下缘平均前移 7 8mm ,颅底相对上颌骨的夹角平均增加 9°,提示术后眼球突出度和颜面外形接近正常同龄人。结论　颅面截骨后即期前移 ,或者截骨手术后用骨牵引方式逐渐前移颅面结构 ,以增加眼眶的容积 ,是治疗颅面发育不良所致突眼症的最佳方法。     

Graves’ exophthalmos: Volumetric assessment of orbital expansion

INTRODUCTION:

Graves’ ophthalmopathy is characterized by an increase in the volume of orbital soft tissue contents and an associated increase in intraorbital pressure. Surgical expansion of bony orbital volume is therefore an effective method of treating moderate to severe exophthalmos. Numerous correlations between specific decompression procedures and reduction of proptosis have been made. The main emphasis of the majority of these studies, however, appears to be of a qualitative nature rather than quantitative.

OBJECTIVES:

To quantitatively examine the consequences of surgical orbital decompression in the treatment of severe Graves’ exophthalmos, with respect to changes in ocular globe projection and orbital soft tissue and bony volume.

MATERIAL AND METHODS:

A series of three patients (five orbits) with severe exophthalmos were evaluated. All patients were operated on by a single surgeon using a standard technique of orbitozygmatic osteotomy in conjunction with three-wall orbital decompression and release of periorbita. Data obtained from standardized preoperative and three-month postoperative computed tomography scans were transferred to an offline computer workstation. Scalar and volumetric parameters were quantitatively analyzed to determine changes in globe projection in relation to intraorbital volume differences.

RESULTS:

Following surgery, mean globe retrodisplacement from the lateral orbital rim and from the optic foramen were 6.7 mm and 3.3 mm, respectively. Osteotomy and decompression were effective in producing an 18.6% increase in bony orbital volume. However, the volume of intraorbital soft tissues increased substantially following surgery, with a 23.4% increase in orbital fat volume and a 12.2% increase in neurovascular tissue volume.

CONCLUSIONS:

The degree of globe retrodisplacement achieved by surgical expansion of the bony orbital cavity in patients with Graves’ ophthalmopathy may be less than anticipated, due to a post-operative increase in the intraorbital soft tissue volumes.     

Graves眼病眶部生长抑素受体显像研究

目的用99Tcm-奥曲肽(octreotide)SPECT眼眶显像评价Graves眼病活动度和预测免疫抑制疗效。方法Graves眼病患者39例,静脉注射925MBq99Tcmoctreotide后3h进行SPECT眼眶显像,利用感兴趣区技术,计算双侧眼眶(O)枕叶(OC)放射性比值。然后所有患者接受甲基强的松龙冲击治疗,计算治疗前和治疗1个月时的眼病指数(GOI)和临床活动度评分(CAS)。结果有效组34例,OOC比值为1.76±0.17;无效组5例,OOC比值为1.26±0.19(P<0.001)。OOC比值与治疗前CAS呈正相关(r=0.47,P<0.001),与治疗前后眼病指数差值(疗效)呈正相关(r=0.55,P<0.001)。OOC比值接受器工作特性(ROC)曲线下面积为0.971,当OOC比值取1.37时,阳性预测值为97%,阴性预测值为80%。结论OOC比值可反映Graves眼病患者眼病活动度和预测其免疫抑制疗效。