经鼻内镜视神经减压术治疗外伤性视神经病变分析

Transnasal endoscopic optic nerve decompression for traumatic optic neuropathy： analysis of 155 cases

目的探讨经鼻内镜视神经减压术治疗外伤性视神经病变的临床结局。方法回顾分析155例外伤性视神经病变患者临床特征，总结经鼻内镜视神经减压术治疗效果及预后，通过Logistic回归分析筛选影响预后的关键因素。结果（1）随访3～60个月。总体疗效44．5％，40例伤后残余光感以上视力患者疗效87．5％，115例伤后无光感患者疗效29．6％。（2）伤后是否残余视力、手术时机与患者总体疗效相关（OR=0．04、4．62，P〈0．01），伤后视力丧失缓急、手术时机与无光感患者疗效相关（OR=0．22、6．34，P〈0．05），其中伤后残余视力、伤后视力延迟丧失是保护因素，而手术时机超过7d是危险因素；性别、年龄、伤后昏迷时间、术前激素治疗时间、不同术者、视神经管骨折部位、神经鞘膜切开与否、术后激素治疗时间等因素与疗效不相关（P〉0．05）。（3）术中发生脑脊液鼻漏1例，同期手术修补成功；术后发生视力短暂下降2例，最终视力提高。结论经鼻内镜视神经减压术治疗外伤性视神经病变安全、有效，但对于外伤后立即失明患者疗效较差。手术对象宜选择外伤后残余视力或外伤后视力延迟丧失患者，手术时机应力争在外伤后7d以内。

Objective To explore the outcome of transnasal endoscopic optic nerve decompression （TEOND） for traumatic optic neuropathy （TON）. Methods The clinical data of 155 consecutive patients with TON treated with TEOND after failure of mega-dose steroid therapy were retrospectively analyzed, their outcomes were summarized after follow-up, and then Logistic regression was used to analyze the prognosisrelated information to explore the factors influencing prognosis. Results Patients were followed up for 3 - 60 months. The total effective rate of the 155 patients was 44.5%. The effective rate of the patients with light perception or better vision was 87.5%, much higher than that of the patients without light perception （29.6%）. Eyesight was improved, mostly occurring 1 -5 days after operation and lasting for 1 -3 months, in 69 patients. Residual vision degree after trauma （ OR = 0.04） and the interval between injury and surgery （OR = 4.62 ） were significant prognostic factors of the general effect （P 〈 0.01 ）, and the gradual or immediate visual loss history （ OR = 0.22 ） and the interval between injury and surgery （ OR = 6.34 ） were significant to the outcomes of the patients with no light perception （ P 〈 0.05 ）. Sex, age, duration of coma after trauma, pre- and post-operative duration of steroid treatment, operators, fracture site of optic canal, and nerve sheath incision were not correlated to the outcomes of patients （ all P 〉 0.05 ）. Intraoperative cerebrospinal fluid rhinorrhea and postoperative transient visual loss occurred in one and the other two cases, respectively, but these conditions were resolved successfully. Conclusion TEOND is effective and safe for TON patients, but the visual outcome is poor for the immediate blindness cases. The surgery is indicated for the patients with some residual vision or with a gradual visual loss and is suggested to perform early within seven days after injury.