曲安奈德结膜上方穹隆部深层注射治疗甲状腺相关眼病上睑退缩的临床观察

Triamcinolone acetonide deep fornix injection for the treatment of upper eyelid retraction in patients with thyroid-associated ophthalmopathy

目的评价曲安奈德结膜上方穹隆部深层注射治疗甲状腺相关眼病上睑退缩的效果。方法病例对照研究。选取2015年10月至2018年12月首都医科大学附属北京友谊医院眼科就诊的53例(64只眼)甲状腺相关眼病所致上睑退缩患者的病历及随访资料,其中33例(39只眼)患者采用结膜上方穹隆部深层曲安奈德注射治疗(治疗组);20例(25只眼)仅观察随访(观察组)。治疗组曲安奈德每次20 mg结膜上方穹隆部深层注射,每月1次,治疗效果稳定后停药并随访。对两组患者治疗或随访前、后上睑缘距瞳孔距离(MRD1)、甲状腺眼病生活质量(TED-QOL)评分、临床活动度评分(CAS)、眼球突出度等指标进行比较。采用配对t检验及独立样本t检验等进行统计学分析。结果治疗组男性6例,女性27例,年龄(43±12)岁;观察组男性5例,女性15例,年龄(40±13)岁,两组性别、年龄、眼睑退缩病程及首次就诊时MRD1,TED-QOL评分,CAS,眼球突出度,眼压,B超测量的上、下、内、外直肌直径比较差异均无统计学意义(均P>0.05)。治疗组曲安奈德注射次数为(2.18±0.94)次(范围1~5次);治疗后随访(6.74±3.89)个月,MRD1由(6.85±0.88)mm降低至(4.38±1.04)mm、TED-QOL评分由(22.03±4.33)分降低至(7.91±3.25)分,CAS由(2.82±0.39)分降低至(0.97±0.39)分,差异均有统计学意义(t=14.68,21.36,20.92;均P<0.01);眼球突出度、眼压、B超测量的各直肌直径治疗前、后差异均无统计学意义(均P>0.05)。观察组随访(8.65±5.15)个月后眼睑退缩亦有好转,但治疗组改善更明显,治疗组治疗前后的MRD1、TED-QOL评分、CAS差值分别为(2.46±1.05)mm、(14.06±3.80)分、(1.85±0.51)分,均高于观察组随访前后的差值[(0.32±0.75)mm、(3.24±2.86)分、(0.56±0.58)分],差异均有统计学意义(t=8.86,11.90,8.98;均P<0.01)。两组患者在随访期间上睑退缩均无复发。治疗组中出现短暂性眼压升高5例(6只眼),经降眼压治疗后恢复正常;3例女性患者有月经改变。结论结膜上方穹隆部深层注射曲安奈德治疗甲状腺相关眼病所致上睑退缩是一种简单、有效的治疗方法,能够显著减轻上睑退缩症状,改善患者生活质量。(中华眼科杂志,2020,56:524-529)

Objective To evaluate the efficacy of triamcinolone acetonide deep fornix injection for the treatment of upper eyelid retraction caused by thyroid-associated ophthalmopathy(TAO).Methods Case-control study.A retrospective analysis was conducted on 64 eyes in 53 patients with upper eyelid retraction caused by TAO from October 2015 to December 2018.Thirty-nine eyes in 33 patients diagnosed with TAO with upper eyelid retraction were treated with triamcinolone acetonide deep fornix injection(20 mg),once per month until the therapeutic effect was stable,as the treatment group.Twenty-five eyes in 20 patients were not treated(the observation group).The ocular examination indexes of the two groups were compared.Paired t-test and independent sample t-test were used for statistical analysis.Results There were 6 males and 27 females in the treatment group,aged(43±12)years,and 5 males and 15 females in the observation group,aged(40±13)years.There was no significant difference in gender,age,history and baseline ocular examination indexes between the two groups(all P>0.05).In the treatment group,the number of injections was(2.18±0.94)times(range,1 to 5 times).After(6.74±3.89)months of follow-up,the marginal reflex distance(MRD1)was reduced from(6.85±0.88)mm to(4.38±1.04)mm,the score of quality of life in thyroid eye disease(TED-QOL)was reduced from 22.03±4.33 to 7.91±3.25,and the clinical activity score(CAS)was reduced from 2.82±0.39 to 0.97±0.39(t=14.68,21.36,20.92;all P<0.01).There was no statistically significant difference in the degree of exophthalmos,intraocular pressure,the diameter of the rectus muscle measured by B-ultrasound before and after treatment(all P>0.05).After(8.65±5.15)months of follow-up,the eyelid retraction also improved in the observation group,but the improvement was more obvious in the treatment group.The differences of MRD1,TED-QOL and CAS before and after treatment in the treatment group were(2.46±1.05)mm,14.06±3.80 and 1.85±0.51 respectively,which were significantly higher than those before and after the follow-up in the observation group[(0.32±0.75)mm,3.24±2.86 and 0.56±0.58,respectively;t=8.86,11.90,8.98;all P<0.01].There was no recurrence in the two groups.In the treatment group,5 patients(6 eyes)showed a transient intraocular pressure rise,which was controlled after medication;3 women had menstrual changes.Conclusions Deep fornix injection of triamcinolone acetonide for treating upper eyelid retraction is convenient and effective.It can significantly reduce symptoms and improve patients'quality of life.(Chin J Ophthalmol,2020,56:524-529)