眼眶平衡减压术与经鼻内窥镜内下壁减压术治疗高眶压的疗效对比

Comparison of the effects of balanced orbital decompression and endoscopic transnasal inferomedial wall decompression with the high orbital pressure

目的探讨眼眶平衡减压术与经鼻内窥镜内下壁减压术治疗Graves眼病(GO)高眶压的手术效果及相关并发症。方法采用队列研究设计,纳入天津医科大学眼科医院2016年12月至2019年12月接受眼眶内外壁平衡减压术或鼻内窥镜行内下壁减压术的GO患者56例,随访6个月。患者根据手术方式的不同分成2个组,平衡眶减压术组24例33眼,采用经泪阜结膜入路的内壁减压术联合保留眶缘的眶深外壁减压术;经鼻内窥镜内下壁减压术组36例51眼,采用经鼻内窥镜内下壁减压术。对2个组患者基本情况、手术细节、影像学资料、手术前后眼球突出度变化、眶压变化、最佳矫正视力(BCVA)变化,术后相关并发症及其处理进行分析和比较。结果平衡眶减压术组术前和术后眼球突出度分别是(21.03±3.11)mm和(17.06±2.55)mm,差异有统计学意义(P<0.05);经鼻内窥镜内下壁减压术组术前和术后眼球突出度分别是(20.51±3.53)mm和(16.28±2.96)mm,差异有统计学意义(P<0.05)。平衡眶减压术组和经鼻内窥镜内下壁减压术组术后眼球回缩量比较,差异无统计学意义(P>0.05);所有患者术前均有不同程度的高眶压,术后随访6个月后眶压恢复正常;平衡眶减压术组与经鼻内窥镜内下壁减压术组中合并有压迫性视神经病变(DON)患者术后BCVA较术前均明显提高,差异均有统计学意义(Z=-3.524、-4.376,均P<0.01);经鼻内窥镜内下壁减压术组术后BCVA提高量为0.72(0.40,0.80),高于平衡减压术组的0.48(0.25,0.67),差异有统计学意义(Z=-2.418,P=0.016);平衡减压术组手术相关并发症发生率为21.2%(7/33),低于经鼻内窥镜内下壁减压术组的47.0%(24/51),差异有统计学意义(χ2=5.748,P=0.017)。结论眼眶平衡减压术和经鼻内窥镜内下壁减压术均可有效改善GO患者眼球突出情况,降低眶压。与眼眶平衡减压术比较,对于合并有DON的患者,经鼻内窥镜内下壁减压术对视力的改善更明显,但手术相关并发症发生率较高。

Objective To explore the surgical outcomes and surgery-related complications of balanced orbital decompression and endoscopic transnasal inferomedial wall decompression for Grave's ophthalmopathy(GO).Methods A cohort study was performed.The 56 GO patients who underwent balanced orbital decompression or endoscopic transnasal inferomedial wall decompression in the Tianjin Medical University Eye Hospital from December 2016 to December 2019 were enrolled.The follow-up time was 6 months.Patients were divided into two groups according to the operation modes.Thirty-three eyes of 24 subjects were given deep lateral wall rim-sparing orbital decompression and transcaruncular medial wall decompression,and 51 eyes of 36 cases were given endoscopic transnasal inferomedial wall decompression.The demographics,surgical details,imaging data,postoperative changes of exophthalmos,best corrected visual acuity(BCVA),orbital pressure and diplopia,surgery-related complications and further treatment were analyzed and compared.This study followed the Declaration of Helsinki and was approved by the Ethics Committee of Tianjin Medical University Eye Hospital[No.2020KY(L)-39].All subjects signed informed consent.Results The exophthalmos was(21.03±3.11)mm before operation,which was significantly higher than(17.06±2.55)mm after operation in the balanced orbital decompression group(P<0.05).The exophthalmos was(20.51±3.53)mm before operation,which was significantly higher than(16.28±2.96)mm after operation in the endoscopic transnasal inferomedial wall decompression group(P<0.05).No significant difference in the mean reduction of proptosis was found between the two groups(P>0.05).All the subjects were accompanied with increase of intraorbital pressure before operation.The intraorbital pressure returned to normal at 6 months after operation.The postoperative BCVA of subjects with dysthyroid optic neuropathy(DON)were significantly higher than preoperative values(Z=-3.524,-4.376;both atP<0.01).The postoperative improvement values of BCVA were 0.48(0.25,0.67)and 0.72(0.40,0.80)in the balanced orbital decompression group and the endoscopic transnasal inferomedial wall decompression group,respectively,with a significant difference between the two groups(Z=-2.481,P=0.016).The incidence of complications in the balanced orbital decompression group was 21.2%(7/33),which was significantly lower than 47.0%(24/51)in the endoscopic transnasal inferomedial wall decompression group(χ2=5.748,P=0.017).Conclusion The two kinds surgical methods can effectively reduce the degree of exophthalmos and orbital pressure.Endoscopic transnasal inferomedial wall decompression can provide better improvement of visual function in patients with DON,but has a higher risk of surgery-related complications in comparison with the balanced orbital decompression.