外伤性视神经损伤经鼻内镜视神经减压手术时期选择及疗效观察

Timing of operation and therapeutic effect of endoscopic optic nerve decompression for traumatic optic neuropathy

目的观察鼻内镜下视神经减压术治疗外伤性视神经损伤的疗效和最佳手术时间。方法对1998年4月至2007年3月90例头部和（或）颌面外伤后发生93眼外伤性视神经损伤的患者进行回顾性分析。所有患者接受鼻内镜视神经减压术前对药物治疗均无反应或效果不佳。受伤至手术时间1～97d，中位手术时间5．5d。术前无视力71眼，有视力22眼（1眼光感，5眼眼前手动，13眼眼前指数，1眼视力0．04，2眼视力0．1）。随访时间6d-2年，中位随访时间8d。结果视神经减压术后35例（36眼，38．7％）视力有改善，53例（55眼，59．1％）无变化，2例（2眼，2．2％）视力下降。术前有视力的患者中，视力改善者达68．2％（15／22眼），外伤后立即或逐渐失明的患者中视力改善分别只有22．9％（8／35眼，仅2眼视力恢复到大于0．02）和36．1％（13／36眼，5眼视力恢复到大于0．02），术前有视力和无视力两组视力术后恢复差异非常显著（X^2=11．864，P〈0．01）。无视力的患者中，伤后3d内手术视力改善为41．2％（7／17眼），3d后手术视力改善下降到25．9％（14／54眼），但两者之间差异无统计学意义（X^2=1．46，P〉0．05）。不同受伤部位比较，视神经管内外侧壁同时骨折手术效果最好（55．6％，10／18眼），其次为内侧壁骨折（45．7％，21／46眼），最差为没有骨折（20％，4／20眼）和单纯外侧壁骨折患者（11．1％，1／9眼）。结论为了挽救患者视力，应尽早行鼻内镜视神经减压手术，即使伤后立即丧失视力也不要放弃手术治疗。但手术后所获得的满意的视力恢复仍然需要进一步研究。

Objective To observe the optimal timing of operation and the therapeutic effect of endoscopic optic nerve decompression for traumatic optic neuropathy （TON）. Methods The clinical records of 90 consecutive patients with TON （93 eyes） after head and/or maxillofacial trauma from April 1998 to March 2007 were reviewed and analyzed. All patients were either unresponsive or intolerant to medication before they underwent intranasal endoscopic optic nerve decompression. The time interval between the injury and operation ranged from one day to 97 days （median 5.5 days）. Among the 93 eyes, there were 71 eyes with no visual acuity before operation and 22 eyes with residue visual acuity, including light perception in 1 eye, hand movement in 5 eyes, counting fingers in t3 eyes, 0. 04 in 1 eye, and 0. 1 in 2 eyes. Duration of follow-up ranged from 6 days to two years （median 8 days ）. Results After decompression, 35 patients （36/93 eyes, 38.7% ） showed improvement of visual acuity, 53 patients （55 eyes, 59. 1%） remained the same as before operation, while 2 patients （2 eyes, 2.2%） showed decreased visual acuity. Among patients with visual acuity beyond light perception before decompression, 68.2% of them （ 15/22 eyes） experienced visual improvement ,whereas only 22.9% （8/35 eyes, 0. 02 in two eyes） among patients who lost visual acuity immediately after injury, and 36. 1% （ 13/36 eyes, 0. 02 in five eyes） among those who lost visual acuity gradually after injury. There was a significant difference in visual improvement between group with visual acuity and group with no visual acuity （ X^2 = 11. 864, P 〈 0. 01 ）. Among patients with no visual acuity, 41.2% of those （7/17 eyes） who underwent operation within 3 days of injury, experienced improvement in visual acuity, compared with 25. 9% （14/54 eyes） for those who underwent the operation more than 3 days after injury. It was indicated that no significant difference in visual improvement between these two groups （ X^2 = 1.46, P 〉 0. 05 ）. When comparing different sites of fracture, the effect of surgery was the most desirable （55.6%, 10/18 eyes improved） if the fracture occurred simultaneously in both exterior and interior walls of optic canal, followed by the interior wall fracture （45.7%, 21/46 eyes）. The operation was less effective if there was no fraction （20%, 4/20 eyes） or if the fracture occurred in exterior wall alone （ 11. 1%, 1/9 eyes）. Conclusions Endoscopic optic nerve decompression is a minimally invasive procedure with no adverse cosmetic effects. Early operation is recommended for saving vision, even though visual acuity is lost immediately after injury. However, the satisfactory clinical effects of endoscopic optic nerve decompression require further study.