目的

探讨甲状腺相关性眼病（TAO）所致限制性斜视的临床特征和手术治疗效果。

方法

选取2019年1月至2023年3月于武汉大学人民医院眼Ⅳ科因TAO所致限制性斜视行手术治疗TAO患者48例（68只眼）的临床资料。其中，男性33例（44只眼），女性15例（24只眼）；年龄33～66岁，平均年龄为（51.7±10.3）岁。所有患者根据术前眼球运动、影像学成像及术中牵拉试验确定受累肌肉，并行受累肌肉的减弱术，包括直肌悬吊术、直肌后徙术、直肌断腱术及A型肉毒素注射，必要时联合拮抗肌加强术。术后随访6个月或1年，检查并记录患者手术前与末次随访斜视度、复视情况、眼压、视力及突眼度。年龄、眼球运动受限、斜视度、术眼眼压、视力及突眼度情况等计量资料符合正态分布，采用¯x±s描述，术前术后比较采用配对t检验。病程和甲状腺功能障碍与斜视间隔时间不符合正态分布，采用四分位数描述；计数资料用例数和百分比描述。

结果

48例（68只眼）患者斜视病程为5～108个月，中位病程为12个月，甲状腺功能障碍病程为7～120个月，中位病程为20个月；甲状腺功能障碍与斜视中位间隔时间为0～114个月，中位间隔时间为6个月。全部患者48例（68只眼）中既往诊断为Graves病有45例（64只眼），甲状腺乳头状癌有2例（3只眼），桥本甲状腺炎有1例（1只眼），分别占94.12%、4.41%及1.47%。所有患者眼眶影像学成像均提示存在眼外肌受累。斜视与甲状腺功能异常同时出现者9例（12只眼），斜视后出现甲状腺功能异常者39例（56只眼），分别占18.75%和81.25%。所有患者术前甲状腺功能均无甲状腺功能亢进症表现。垂直斜视合并内斜视者32例（44只眼），垂直斜视合并外斜视者2例（4只眼），垂直斜视者8例（10只眼），内斜视者6例（10只眼），分别占66.67%、4.17%、16.67%及12.50%。眼眶影像学成像显示48例（68只眼）患者均存在不同程度眼外肌受累。其中，存在下直肌受累、上直肌受累、内直肌受累及外直肌受累者分别为40例（61只眼）、31例（46只眼）、26例（45只眼）及8例（10只眼），分别占83.33%、64.58%、54.17%及16.67%。累计共162条眼外肌增粗，存在2条以上眼外肌受累者36例（56只眼），仅为1条眼外肌受累者12例（12只眼），分别占75%和25%。45例（68只眼）中有81条眼外肌行手术治疗，均为直肌。78条直肌行减弱手术，单条肌肉减弱术者28例（28只眼），两条肌肉减弱术者14例（28只眼），两条以上肌肉减弱术者6例（12只眼），分别占58.33%、29.17%及12.5%。45例（64只眼）术眼术前眼压平均值为（24.19±9.26）mmHg（1 mmHg＝0.133 kPa），术后眼压平均值为（19.99±7.00）mmHg，术后眼压较术前降低，比较的差异有统计学意义（t＝5.695，P＜0.05）；术前平均视力为（4.82±0.50）最小分辨角的对数（logMAR），术后平均视力为（4.86±0.45）logMAR，术后视力有明显提升，比较的差异有统计学意义（t＝1.995，P＜0.05）；术眼术前突眼度平均值为（19.80±2.22）mm，术后突眼度平均值为（17.60±2.14）mm，术后突眼度较术前回退，比较的差异有统计学意义（t＝14.408，P＜0.05）。

结论

TAO所致限制性斜视患者主要表现为多条眼外肌受累的斜视，下直肌和内直肌常受累，受限肌肉的减弱术有效，必要时可联合拮抗肌加强术。

Objective

The aim of this study is to analyze the clinical characteristics and surgical outcomes of restrictive strabismus caused by thyroid-associated ophthalmopathy（TAO）.

Methods

A total of 48 TAO patients（68 eyes）who underwent surgical intervention for restrictive strabismus at the Department of Ophthalmology，Renmin Hospital of Wuhan University，between January 2019 and March 2023 were retrospectively collected.The final participants included 33 males（44 eyes）and 15 females（24 eyes）with amean age of（51.7±10.3）years（ranging from 33 to 66）.Affected extraocularmuscles were identified preoperatively via ocularmotility assessments，imaging，and intraoperative forced pull tests.Surgical strategies included extraocularmuscle tenotomy，suspension surgery，retraction surgery，or type A botulinum toxin injection，with additional strengthening surgery for residual deviation.Patientswere followed up for 6 months or 1 year after surgery and analyzed for differences of in ocular deviation，diplopia，intraocular pressure，visual acuity，and proptosis between the preoperative period and the last follow-up.Measurements of age，limitation degree of ocularmotility，strabismus deviation，intraocular pressure，visual acuity，and proptosiswere described as¯x±s when they conformed to normal distribution，and compared by t tests；paired t tests were used for preoperative and postoperative comparisons.Disease duration and the interval between thyroid dysfunction and strabismus were described by quartiles due to they did not conform to normal distribution；count data were described by number of cases and percentage.

Results

The duration of strabismus ranged from 5 to 108 months，with amedian duration of12 months，and the duration of thyroid dysfunction ranged from 7 to 120 months，with amedian duration of20months；themedian interval between thyroid dysfunction and strabismus ranged from 0 to 114 months，with a median interval of 6 months.45 patients（64 eyes）had a previous diagnosis of TAO，2 cases（3 eyes）with papillary thyroid carcinoma，and 1 case（1 eye）with Hashimoto′s thyroiditis，accounting for 94.12%，4.41% and 1.47%，respectively.All patients had orbital imaging suggestive of extraocularmuscle involvement.Strabismus and thyroid function abnormality appeared simultaneously in 9 cases（12 eyes），accounting for 18.75%；39 cases（56 eyes）with strabismus after thyroid function abnormality，accounting for 81.25%.None of the patients showed hyperthyroidism in their preoperative thyroid function.Strabismus patterns included vertical deviation with esotropia（32 cases，44 eyes，accounting for 66.67%），vertical deviation with exotropia（2 cases，4 eyes，accounting for 4.17%），isolated vertical deviation（8 cases，10 eyes，16.67%），and isolated esotropia（6 cases，10 eyes，accounting for 12.50%）.Orbital imaging demonstrated extraocular muscle thickening in 162 muscles across 48 patients（68 eyes）.Specifically，involvement of the inferior rectus（40 cases，61 eyes，accounting for 83.33%），superior rectus（31 cases，46 eyes，accounting for 64.58%），medial rectus（26 cases，45 eyes，accounting for 54.17%），and lateral rectus（8 cases，10 eyes，accounting for 16.67%）was observed.Multimuscular involvement（≥2 muscles）occurred in 36 cases（56 eyes，accounting for 75%），while 12 cases（12 eyes，accounting for 25%）exhibited singlemuscle involvement.Surgical intervention targeted 81 rectus muscles（78 weakened，3 strengthened）.Weakening procedures included single-muscle recession（28 cases，28 eyes，accounting for58.33%），twomuscle recession（14 cases，28 eyes，accounting for 29.17%），and multimuscular recession（6 cases，12 eyes，accounting for 12.5%）.The average preoperative intraocular pressure of 45 cases（64 eyes）was（24.19±9.26）mmHg（1 mmHg＝0.133 kPa），and the average postoperative intraocular pressure was（19.99±7.00）mmHg.The postoperative intraocular pressure decreased compared to preoperative levels，and the differencewas statistically significant（t＝5.695，P＜0.05）.The preoperative average visual acuity was（4.82±0.50）logarithm of theminimum angle of resolution（logMAR），and the postoperative average visual acuity was（4.86±0.45）logMAR.There was a significant improvement in postoperative visual acuity，and the difference was statistically significant（t＝1.995，P＜0.05）.The average preoperative protrusion degree was（19.80±2.22）mm，and the average postoperative protrusion degree was（17.60±2.14）mm.The postoperative protrusion degree decreased compared to preoperative，and the difference was statistically significant（t＝14.408，P＜0.05）.

Conclusions

TAO-induced restrictive strabismus predominantly involvesmultiple extraocularmuscles，particularly the inferior and medial rectus.Weakening procedures for restricted muscles，with adjunctive antagonist muscle strengthening when necessary，effectively restore ocular alignment and improve functional outcomes.