内镜下经筛径路眶内侧壁减压联合脂肪减压术治疗Graves眼病

Endoscopic trans-ethmoid medial orbital wall decompression combined with intraconal fat decompression for Graves＇ ophthalmopathy

目的探讨内镜下经筛径路眶内侧壁减压术联合内镜下经筛径路眶肌锥内脂肪减压术治疗Graves眼病（Graves’ophthalmopathy，GO）的可行性，并分析其疗效。方法对2006年10月至2011年5月因并发眶尖拥挤视神经病变而接受眶减压手术的29例GO患者进行回顾性分析。所有患者术前确诊为非组织活动期，均因视力下降、视野缺损或色觉障碍，同时合并眼球突出而接受内镜下经筛径路眶内侧壁减压术联合肌锥内眶脂肪减压术，术后定期随访。根据术后9个月视力、色觉改善程度，以及眼球突出度矫正度、复视等并发症判断疗效。结果共收集资料齐全的GO患者29例（45眼）。术后9个月，44眼（97．8％）视力明显改善，视力从术前（元±s，下同）的-0．65±0．30提高至-0．24±0．22，视力平均提高达0．55±0．17，手术前后比较差异有统计学意义（t=-13．012，P〈0．001）；29眼术前色觉障碍者，23眼（79．3％）术后明显改善；术后双眼眼球对称度达100％，手术前后比较，平均眼球突出矫正度达（7．07±1．59）mm（4～11mm）。术后所有病例双眼眼球突出度相差〈2mm，除1例术后复视加重外，术后无一例新发复视、视力下降、眶内出血等并发症发生。结论内镜下经筛径路眶内侧壁减压术联合肌锥内眶脂肪减压术在实现眶尖部减压的同时可以达到有效矫正眼球突出度的效果，且具有微创，无颜面部瘢痕，术后复视、眼球移位等发生率极低的优点，该术式是治疗GO并发眶尖拥挤视神经病变患者的安全有效的手段之一。

Objective To present a new mini-invasive surgery for compressive optic neuropathy （CON） in Graves＇ ophthalmopathy （GO） by adequately decompressing the orbital apex and correcting proptosis, and to analyze its results. Methods A retrospective chart was reviewed in 29 patients receiving orbital decompression for the treatment of CON secondary to GO from October 2006 to May 2011. All patients diagnosed CON were in stable and inactive phase of GO at least for 6 months. All patients received endoscopic transethmoid medial orbital wall decompression to reduce the compression on the orbital apex. In the meanwhile, an endoscopic transethmoid intraeonal fat-removal orbital decompression was performed to remove parts of intraconal fat with a special aspiration/cutting instrument to further reduce the proptosis. All patients were followed up periodically. Results of improvement of visual acuity （ VA）, color vision, and amount of proptosis reduction and incidence of induced diplopia 9 months after surgery was recorded for analysis its feasibility. Results Forty-five orbits of 29 patients were included in the study. At the 9 months review, 44 of 45 eyes （97.8%） improved their VA from -0.65± 0.30 （x±s） preoperatively to -0.24 ± 0.22, with a mean improvement of 0.55 ±0.17 （t = - 13. 012,P 〈 0.001 ）, 23 of 29 eyes （79.3%） had improved color vision （ P 〈 0. 001 ） , and the mean reduction in proptosis was （ 7.07± 1.59 ） mm （ range 4- 11 mm）. Postoperative symmetry to within 2 mm were achieved in all patients. Except 1 patient complaining of deterioration in diplopia following surgery, no patients presented new on-set diplopia postoperatively. Conclusion The endoscopic transethmoid medial orbital wall decompression combined with the endoscopic transethmoid intraconal fat-removal orbital decompression is an effective minimal morbidity for both visional recovery and improvement of proptosis for CON in GO.