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中华眼科医学杂志(电子版)

中华眼科医学杂志(电子版) ›› 2023, Vol. 13 ›› Issue (05) : 268 -272. doi: 10.3877/cma.j.issn.2095-2007.2023.05.003

论著

非开眶小切口内外壁均衡减压术治疗甲状腺相关眼病的临床观察
马瑞, 徐文芹, 李月月, 胡至察, 张国禄, 吴畏, 胡健, 马建民, 杨新吉†()   
  1. 100853　北京，解放军总医院第三医学中心眼科医学部眼眶病外科
    100730　首都医科大学附属北京同仁医院　北京同仁眼科中心　北京市眼科研究所　北京市眼科学与视觉科学重点实验室
  • 收稿日期:2023-10-02 出版日期:2023-10-28
  • 通信作者: 杨新吉
  • 基金资助:
    北京市自然科学基金项目(7222025)

Clinical effects of balanced decompression of the inner and outer walls through non-orbital small incisions in the treatment of thyroid related ophthalmopathy

Rui Ma, Wenqin Xu, Yueyue Li, Zhicha Hu, Guolu Zhang, Wei Wu, Jian Hu, Jianmin Ma, Xinji Yang†()   

  1. Department of Orbital Disease, Senior Department of Ophthalmology, the Third Medical Center of the People′s Liberation Army General Hospital, Beijing 100853, China
    Beijing Tongren Eye Center, Beijing Tongren Hospital, Beijing Ophthalmology & Visual Sciences Key Laboratory, Beijing Institute of Ophthalmology, Capital Medical University, Beijing 100730, China
  • Received:2023-10-02 Published:2023-10-28
  • Corresponding author: Xinji Yang
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马瑞, 徐文芹, 李月月, 胡至察, 张国禄, 吴畏, 胡健, 马建民, 杨新吉. 非开眶小切口内外壁均衡减压术治疗甲状腺相关眼病的临床观察[J]. 中华眼科医学杂志(电子版), 2023, 13(05): 268-272.

Rui Ma, Wenqin Xu, Yueyue Li, Zhicha Hu, Guolu Zhang, Wei Wu, Jian Hu, Jianmin Ma, Xinji Yang. Clinical effects of balanced decompression of the inner and outer walls through non-orbital small incisions in the treatment of thyroid related ophthalmopathy[J]. Chinese Journal of Ophthalmologic Medicine(Electronic Edition), 2023, 13(05): 268-272.

目的

探讨非开眶小切口内外壁均衡减压术治疗甲状腺相关眼病(TAO)的临床效果。

方法

收集2021年1月至2023年1月于解放军总医院第三医学中心眼科医学部眼眶病外科确诊为TAO并行非开眶小切口内外壁均衡减压术的患者25例(40只眼)进行研究。其中，男性8例(10只眼)，女性17例(30只眼)。年龄21～42岁，平均年龄(36.4±6.1)岁。全部患者行非开眶小切口内外壁均衡减压术治疗；其中，眼球运动受限合并限制性斜视者于眼眶减压手术中同时行斜视矫正术。询问并记录所有患者的性别和年龄；检查并记录患者术前和术后3个月的最佳矫正视力(BCVA)、眼球突出度、眼压、眼球运动及复视情况。性别、年龄、眼球运动情况及复视情况使用频数和百分比进行描述；手术前后的BCVA采用中位数和四分间距表示；眼球突出度和眼压经检验符合正态分布以±s表示。患者手术前后的BCVA的比较采用Wilcoxon符号秩和检验，手术前后患眼的眼球突出度和眼压的比较采用配对t检验。

结果

全部患者25例(40只眼)中，术前患者的BCVA中位数为0.8(0.6，1.0)，术后BCVA中位数为0.8(0.6，1.0)，其差异无统计学意义(Z＝5.84，P>0.05)。其中，有2例(2只眼)术前BCVA均为0.6，术后BCVA分别提高至0.8和1.0。术前整体患者的眼球突出度为20～24 mm，平均眼球突出度(21.35±1.15 )mm，术后3个月眼球突出度为14～19 mm，平均眼球突出度(16.95±1.47)mm，较术前眼球突出度降低(4.4±1.03)mm，其差异具有统计学意义(t＝4.454，P<0.05)。术前整体患者眼压(20.8±3.26)mmHg(1 mmHg＝0.133 kPa)，术后3个月眼压(16.95±2.08) mmHg，眼压较术前降低(3.85±2.21)mmHg，其差异具有统计学意义(t＝5.314，P<0.05)。术前，眼球运动受限但无限制性斜视者8例(10只眼)，均有复视症状；术后眼球活动均有不同程度的改善，复视症状减轻。术前眼球运动受限合并限制性斜视者6例(6只眼)，术后眼正位无明显复视者5例(5只眼)；1例(1只眼)患者术后有间歇性外斜视15°，仍有轻度复视症状，但不影响日常生活和阅读。

结论

非开眶小切口内外均衡减压术疗效确切，皮肤切口小而隐秘，无需开眶，适用于美容需求高、眼球突出度低且无严重视神经压迫病变的患者。

关键词: 甲状腺相关眼病, 眼球突出, 眼眶减压术, 复视
Objective

To investigate the clinical effect of balanced orbital decompression without marginotomy on thyroid-associated ophthalmopathy (TAO).

Methods

A total of 25 patients (40 eyes) diagnosed with TAO in the Department of Ophthalmology of the Third Medical Center of the People′s Liberation Army General Hospital and underwent balanced orbital decompression without marginotomy from January 2021 to January 2023 were collected. Among them, 8 cases (10 eyes) were malesand 17 cases (30 eyes) were females with an average age of (36.4±6.14) years (ranged from 21 to 42 years). All patients underwent balanced orbital decompression without marginotomy. For patients with limited eye movement and restrictive strabismus, they underwent strabismus correction surgery simultaneously during orbital decompression surgery. The gender, age, best corrected visual acuity (BCVA), proptosis, intraocular pressure, eye movement, and diplopia of all patients were examined and recorded before and after surgery for 3 months. The gender, age and eye movement was described by frequency and percentage. The BCVA of patients were expressed as median and interquartile before and after surgery and compared by the Wilcoxon signed rank test. The patient′s proptosis and intraocular pressure conformed to normal distribution, and were described by ±s and compared by paired t-test before and after surgery.

Results

Among 25 patients (40 eyes), the median and interquartile of BCVA was 0.8(0.6, 1.0), 0.8(0.6, 1.0) before and after surgery, respectively. There was a significant difference between them (Z=5.84, P>0.05). Among them, the BCVA of 2 cases (2 eyes) before surgery were both 0.6, which reached 0.8 and 1.0 respectively after surgery. The overall proptosis was 20 to 24 mm and the average proptation was (21.35±1.15) mm before surgery. After surgery for 3 months, the proptosis was 14 to 19 mm, and the average proptation was (16.95±1.47) mm, which significantly reduced by (4.4±1.03)mm than that before surgery (t=4.454, P<0.05). The overall intraocular pressure was (20.8±3.26) mmHg (1 mmHg=0.133 kPa) and (16.95±2.08) mmHg before and after surgery, respectively, which significantly reduced by (3.85±2.21)mmHg than that before surgery (t=5.314, P<0.05). Eight cases (10 eyes) with restricted eye movement without restricted strabismus before surgery had symptoms of diplopia, and their ocular activities had been improved to various degrees after surgery, and the symptoms of diplopia were reduced. There were 6 cases (6 eyes) with restricted eye movement restriction and restrictive strabismus before surgery. After surgery, 5 cases (5 eyes) with normal eye position had no obvious diplopia, and 1 case (1 eye) had intermittent exotropia 15° combined with mild diplopia symptoms after surgery, while did not affect daily activities and reading.

Conclusions

The clinical effects of balanced orbital decompression without marginotomy is obvious, which has a small and invisible skin incision without marginotomy and is suitable for patients with high cosmetic demands, low proptosis and without serious compressive optic neuropathy.

Key words: Thyroid-associated ophthalmopathy, Proptosis, Orbital decompression, Diplopia
图1　非开眶小切口内外壁均衡减压手术步骤彩色照相　图1A示外下方结膜切开后向外眦延长；图1B示切开外眦外皮肤约10 mm；图1C示切开骨膜暴露外侧眶壁，磨除外侧壁深部骨皮质　 图2　患者双眼术前与术后外观彩色照相　图2A示术前双眼球明显突出，上眼睑退缩；图2B示术后双眼球突出度明显减小，双眼上睑退缩症状改善　 图3　患者双眼手术前后眼眶水平位计算机断层扫描图像　图3A示可见术前双眼球突出明显；图3B示减压手术后外侧壁及内侧壁骨质不连续，眶内组织向减压区域移位　 图4　手术前后眼球突出度及眼压变化坐标图　图4A示手术后眼球突出度较术前减小；图4B示手术后眼压较术前降低
[1]
Bartalena L, Piantanida E, Gallo D, et al. Epidemiology, Natural History, Risk Factors, and Prevention of Graves′ Orbitopathy[J]. Front Endocrinol (Lausanne), 2020, 11：1－10.
[2]
Lee ACH，Kahaly GJ. Pathophysiology of thyroid－associated orbitopathy[J]. Best Pract Res Clin Endocrinol Metab, 2023，37(2)：1－14.
[3]
Jurek－Matusiak O, Brozek－Madry E, Jastrzebska H, et al. Orbital decompression for thyroid eye disease: surgical treatment outcomes in endocrinological assessment[J]. Endokrynol Pol, 2021, 72(6): 609－617.
[4]
Huang J, Chen M, Liang Y, et al. Integrative metabolic analysis of orbital adipose/connective tissue in patients with thyroid－associated ophthalmopathy[J]. Front Endocrinol, 2022, 13: 1001349.
[5]
Zhang T, Ye H, Xiao W, et al. Corneal Morphological and Biomechanical Changes in Thyroid－Associated Ophthalmopathy[J]. Cornea, 2023, PMID: 37607298.
[6]
Dolman PJ. Dysthyroid optic neuropathy: evaluation and management[J]. J Endocrinol Invest, 2021, 44(3): 421－429.
[7]
Parrilla C, Mele DA, Gelli S, et al. Multidisciplinary approach to orbital decompression. A review[J]. Acta Otorhinolaryngol Ital, 2021, 41(Suppl. 1): S90－S101.
[8]
European Group on Graves O, Mourits MP, Bijl H, et al. Outcome of orbital decompression for disfiguring proptosis in patients with Graves′ orbitopathy using various surgical procedures[J]. Br J Ophthalmol, 2009, 93(11): 1518－1523.
[9]
Cheng AM, Wei YH, Tighe S, et al. Long－term outcomes of orbital fat decompression in Graves′ orbitopathy[J]. Br J Ophthalmol, 2018, 102(1): 69－73.
[10]
Boboridis KG, Gogakos A, Krassas GE. Orbital fat decompression for Graves' orbitopathy: a literature review[J]. Pediatr Endocrinol Rev, 2010, 7 (Suppl 2): 222－226.
[11]
Juniat V, Abbeel L, McGilligan JA, et al. Endoscopic Orbital Decompression by Oculoplastic Surgeons for Proptosis in Thyroid Eye Disease[J]. Ophthalmic Plast Reconstr Surg, 2019, 35(6): 590－593.
[12]
Korkmaz S，Konuk O. Surgical treatment of dysthyroid optic neuropathy: long－term visual outcomes with comparison of 2－wall versus 3－wall orbital decompression[J]. Curr Eye Res, 2016, 41(2): 159－164.
[13]
Rajabi MT, Tabary M, Baharnoori S, et al. Orbital anatomical parameters affecting outcome of deep lateral orbital wall decompression[J]. Eur J Ophthalmol, 2021, 31(4): 2069－2075.
[14]
Rootman DB. Orbital decompression for thyroid eye disease[J]. Surv Ophthalmol, 2018, 63(1): 86－104.
[15]
王毅 ，肖利华，杨忠昆，等. 改良眼眶减压术治疗重度甲状腺相关眼病的疗效观察[J]. 中华眼科杂志，2013，49(3)：242－250.
[16]
Takahashi Y, Kang H, Kakizaki H. Lower incidence of chemosis with the Berke incision approach versus the swinging eyelid approach after deep lateral orbital wall decompression[J]. J Plast Surg Hand Surg, 2016, 50(1): 15－18.
[17]
杨华胜，叶慧菁. 甲状腺相关眼病眼眶减压手术经鼻内镜入路与外部切口入路孰优孰劣[J]. 中华眼科杂志，2018，54(7)：484－487.
[18]
Fu W. Changes of Volume Parameters in the Treatment of Graves Ophthalmopathy by Endoscopic Transethmoidal Decompression of the Orbital Inner Wall Combined with Fat Decompression[J]. Scanning, 2022: 1－6.
[19]
Jefferis JM, Jones RK, Currie ZI, et al. Orbital decompression for thyroid eye disease: methods, outcomes, and complications[J]. Eye (Lond), 2018, 32(3): 626－636.
[20]
Serafino M, Fogagnolo P, Trivedi RH, et al. Torsional diplopia after orbital decompression and strabismus surgery[J]. Eur J Ophthalmol, 2010, 20(2): 437－441.
[21]
Seibel I, Hofmann VM, Sonmez H, et al. Medial and mediolateral orbital decompression in intractable Graves' Orbitopathy[J]. Auris Nasus Larynx, 2017, 44(4): 428－434.
[22]
Fichter N，Guthoff RF. Results after En Bloc Lateral Wall Decompression Surgery with Orbital Fat Resection in 111 Patients with Graves′ Orbitopathy[J]. Int J Endocrinol, 2015: 1－9.
[23]
Wu CY, Niziol LM, Musch DC, et al. Thyroid－Related Orbital Decompression Surgery: A Multivariate Analysis of Risk Factors and Outcomes[J]. Ophthalmic Plast Reconstr Surg, 2017, 33(3): 189－195.
[24]
王毅，李月月，杨娜，等. 最大化眼眶减压术治疗重度甲状腺相关眼病视神经病变的疗效及影响因素[J].中华眼科杂志，2017, 53(6)：416－423.
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