微创多壁眼眶减压术治疗轻和中度甲状腺相关眼病的眼球突出

Multi-wall orbital decompression for disfiguring proptosis in patients with mild or moderate thyroid eye disease

目的观察经结膜和双重睑皮肤切口的内、下及外壁减压术改善甲状腺相关眼病（TAO）眼球突出及外观损伤的疗效及安全性。方法回顾性系列病例研究。收集2013年12月至2015年12月间武警总医院眼眶病研究所收治的静止期TAO患者18例（28只眼）的临床资料，男、女各3和15例，年龄19~45岁（平均年龄30岁）。患者均行微创多壁眼眶减压术，手术目的为缓解眼球突出，缩小睑裂宽度，消除眶周肿胀。纳入标准：（1）Hertel眼突计测量值14~23 mm；或较对侧眼突出2~7 mm；（2）眼部病情静止且甲状腺功能正常6个月以上；（3）指试眶压正常或（＋）。记录手术前、后最佳矫正视力，眼球突出度，上、下睑缘至角膜中央的距离，复视程度。术后3个月复查CT。比较手术前、后眼球突出度，上、下睑缘至瞳孔中央的距离，采用配对t检验；手术前、后复视变化采用Wilconxon检验。结果患者手术前、后眼球突出度分别为（19.2±2.3）mm和（14.7±1.4）mm，平均回退（4.6±1.7）mm，差异有统计学意义（t=14.08，P〈0.01）。手术前、后瞳孔中央至上睑缘距离分别为（5.1±1.2）mm和（4.9±1.3）mm，上睑退缩改善（0.2±0.5）mm，差异无统计学意义（t=1.73，P=0.095）。手术前、后瞳孔中央至下睑缘距离分别为（5.9±0.9）mm和（4.3±0.7）mm，平均回退（1.6±0.8）mm，差异有统计学意义（t=10.09，P〈0.01）。术后双眼突出度差值为0~2.5 mm，中位数1.0 mm。无术后第一眼位新发复视，2例周边新发复视，2例术后复视得到改善，手术前、后复视程度的差异无统计学意义（Z=743.00，P=0.458）。结论该术式可控性好，安全有效且并发症少，能缓解轻、中度眼球突出，改善下睑退缩，消除眶周肿胀，切口美观隐蔽。

Objective To evaluate the efficacy of orbital decompression by transeonjunetival medial and inferior wall combined transpalpebral lateral wall for disfiguring proptosis with mild or moderate thyroid eye disease （TED）. Methods It is a retrospective case series study. The clinical data of 18 TED cases （28 orbits） between Dec 2013 and Dee 2015 at the Institute of Orbital Diseases of the General Hospital of the Armed Police were reviewed. All the patients underwent mulit-wall orbital decompression to relieve remarkable proptosis, widen eyelid fissure, and swollen eyelid. Inclusion criteria： 1. Hertel value was 14-- 23 mm or over 2--7 mm than contralateral eye; 2.Orbitalpathy has been inactive with normal thyroid function for at least 6 months; 3.Orbital pressure is normal or （±）. Clinical outcomes were recorded including best-corrected visual acuity, exophthalmometry, margin-to-central distance of upper and lower lids, diplopia, and CT scans before and 3 months after surgery. Results The mean protosis of pre-and postoperation were （19.2 ± 2.3） mm and （14.7 ± 1.4） mm with mean reduction was （4.6 ± 1.7） mm （t=14.08, P〈0.01）. Margin-to-central distance of the upperlid of pre- and postoperation were （5.1± 1.2） mm and （4.9± 1.3） mm with mean reduction was （0.2±0.5） mm （t=1.73, P=0.095）. Margin-to-central distance of the lowerlid of pre-and postoperation were （5.9±0.9） mm and （4.3±0.7） mm with mean reduction was （1.6±0.8） mm （t=10.09, P〈0.01）. The difference of bilateral exophthalmos after surgery is 0--2.5 mm （median=1mm）. None of the patients showed new-onset diplopia at primary gaze and two patient showed surrounding gaze diplopia postoperatively. Two patients with diplopia relieved after surgery （Z=743.00, P=0.458）. Conclusions Transconjunctival and transpalpebral medial, inferior, and lateral walls decompression with a hidden incision was a controllable, safe, effective technique with minimal complications in relieving not only mild, moderate proptosis, but also retraction of lowerlid, and swollen eyelids.