A型肉毒毒素辅助治疗Graves眼病的临床观察

Effect of botulinum toxin A on the strabismus and diplopia in the patients with Graves ophthalmopathy

目的 通过对存在恶性突眼的Graves眼病患者受累眼外肌进行A型肉毒毒素注射治疗。观察注射后眼位偏斜及复视恢复的情况，探讨A型肉毒毒素辅助治疗Graves眼病的机理及实用价值。方法 选取我院确诊为伴有恶性突眼的Graves眼病合并眼位偏斜的患者3l例（其中伴有水平偏斜者15例，伴有垂直偏斜者30例）。患者进行眼眶CT扫描、同视机、呱SS屏和斜视度测定等检查后，对其所受累的眼外肌（下直肌24条，内直肌11条，上直肌6条，上睑提肌4条）在肌电图的指引下进行多次重复的A型肉毒毒素肌腹内注射。定期随诊观察注射后的眼位变化及复视程度的变化。结果 31例接受A型肉毒毒素眼外肌注射的患者中，在经过重复注射2～6次后，其斜视度及复视程度均有不同程度的减轻。总体显效率41．9％，有效率51．6％，无效率6．5％．结论 A型肉毒毒素眼外肌内注射是一种能有效缓解Graves眼病患者眼外肌挛缩和减轻复视症状及斜视度的治疗方法。在疾病早期及时应用A型肉毒毒素进行受累眼外肌注射。并适当联合全身或局部激素、免疫抑制剂治疗，对于控制Graves眼病的临床症状可以收到满意的疗效。

Objective To observe the therapeutic effect of botulinum toxin A on the strabismus and diplopia in the patients with malignant exophthalmos and to discuss the mechanism and the value of the adjunctive therapy with botulinum toxin A in Graves ophthalmopathy clinically. Methods Thirtyone patients diagnosed as Graves ophthalmopathy with malignant exophthalmos and strabismus（ 15 cases with horizontal strabismus, 30 cases with vertical strabismus） were collected in this study. After the computerized tomography of fossa orbitalis, synoptophore examination, Hess screen examination, and the determination for the number of degrees of strabismus, the patients received the injection of botulinum toxin A in the tousle belly of the affected extraocular muscles （inferior rectus 24 cases, medial rectus 11 cases, superior rectus 6 cases, and levator palpebrae superioris 4 cases） under the guide of the electromyogram repeatedly. The change of the position of eye and the degree of diplopia were followed up after therapy. Results In all eyes of the 31 patients, the strabismus and diplopia was lessened in different degrees after repeated injection with botulinum toxin A in the affected extraocular muscles for 2 to 6 times. The total apparent rate was 41.9%, effective rate was 51.6%, ineffective rate was 6.5%.Conclusion To inject botulinum toxin A in the tousle belly of the affected extraocular muscles is an effective therapy to lighten the contraction of extraocular muscles,and remission of diplopia symptom and strabismus degree in extraocular muscles. The injection therapy of botulinum toxin A combined with corticostoid and immunosuppressive agent at the early stage of Graves ophthalmopathy can get satisfied therapeutic effect.