Therapeutic difference between orbital decompression and glucocorticoids administration as the first-line treatment for dysthyroid optic neuropathy:a systematic review

To assess all available data to compare the efficacy of glucocorticoids treatment and orbital decompression for dysthyroid optic neuropathy(DON).PubMed,EMBASE,the Cochrane Library databases as well as other sources were searched by two independent reviewers followed by extensive hand-searching for the identification of relevant studies.The primary outcomes were the improvement in visual acuity and responder rate.Secondary outcomes were the proptosis reduction,change in diplopia,and clinical activity score(CAS).One randomized controlled trial,three retrospective case series and one prospective case series met the inclusion criteria.They were divided into intravenous high-dose glucocorticoids(ivGC)group and orbital decompression(OD)group.Both groups demonstrated improvement in visual acuity.In addition,the proportion of patients with improved vision in OD group was higher than that in ivGC group(P<0.001).Post-treatment proptosis reduction was also reported in both groups.Overall,weighted mean in proptosis reduction estimated at 1.64 and 5.45 mm in patients treated with ivGC and OD respectively.This study also presented results regarding pre-existing and new-onset diplopia.Apart from diplopia,a wide variety of minor and major complications were noted in 5 included studies.The most common complication in ivGC group and OD group was Cushing's syndrome and epistaxis respectively.The present systematic review shows that both glucocorticoids treatment and OD are effective in treating DON and OD may work better in improving visual acuity and reducing proptosis.However,high-quality,large-sample,controlled studies need to be performed in the future.

Predictive parameters on CT scan for dysthyroid optic neuropathy

AIM:To evaluate the value of parameters on CT scan in predicting dysthyroid optic neuropathy(DON)and to provide guidance for early diagnosis of DON accordingly.METHODS:A total of 67 eyes of 35 patients with thyroid-associated ophthalmopathy(TAO)were included in this study.Patients were divided into 2 groups(DON group and non-DON group).Parameters were measured on high resolution CT,including muscle index(MI),superior ophthalmic vein(SOV)dilatation,extraocular muscle volume/orbit volume(MV/OV),and intracranial fat prolapsed,and be compared between these 2 groups.The relation between those parameters and visual function[visual acuity(VA)and visual field defect(VF defect)]were also evaluated.RESULTS:MI and MV/OV were significantly higher in DON group(P=0.00035 and P=0.00026).No significant difference was detected regarding intracranial fat prolapse existence and SOV dilatation(P=0.37 and P=0.15).MV/OV was found to have significant negative correlation with both VF defect(R=-0.332,P=0.0273)and VA(R=-0.635,P=0.00)while MI was found to have negative linear correlation with VA only(R=-0.456,P=0.00017).The area under receiver operating characteristic curves was 0.82 for MV/OV and 0.75 for MI.The best performance in detecting DON was achieved when MV/OV is set at 0.20 with 72%sensitivity and 87%specificity and MI is set at 0.52 with 64%sensitivity and 80%specificity.CONCLUSION:MI and MV/OV are predictive parameters for DON.Together with clinical manifestations,MV/OV≥0.2 can be used as a good indicator for DON in TAO patients.

Reduced choroidal peripapillary capillaries in thyroid-associated ophthalmopathy with early stage of dysthyroid optic neuropathy

AIM: To investigate whether the subtle change of choroidal/retinal vessel densities and volumes in thyroidassociated ophthalmopathy(TAO) could be an early sign to detect dysthyroid optic neuropathy(DON). METHODS: This was a retrospective cross-sectional study, and a total of 98 eyes from 50 subjects were enrolled under certain criteria. Thirty-four eyes of normal controls and 64 eyes of TAO, including 39 eyes of DON and 25 eyes of TAO without DON, underwent optical coherence tomography angiography(OCTA) scanning. All the tested parameters of OCTA scanning including choroid radial peripapillary capillaries(RPC), retinal nerve fiber layer(RNFL), and macular ganglion cell complex(GCC) were compared among groups, and the correlation between OCTA parameters and visual function parameters was also investigated. RESULTS: Whole choroidal RPC was significantly reduced in DON(48.24%±0.4978%) compared to normal(50.33%±0.3173%) and TAO without DON(49.16%±0.5463%;P=0.0041). The reduction of whole choroidal RPC was also correlated with visual field(VF) defect in DON(r=0.5422, n=39). Although vision acuity and VF were improved in all the patients with DON after being treated with medical and surgical decompression, the reduction of RPC density were not reversed.CONCLUSION: There is a notable reduction in choroidal RPC in DON, which is correlated with VF defect. The reduction of RPC density could not be reversed immediately by medical and surgical decompression even when vision and VF were improved. These findings suggest that choroidal RPC could be a useful parameter to diagnose and monitor early stage of DON.

Dysthyroidism in Elderly Subjects

Introduction: Aging is associated with an anatomical and functional heterogeneity of the thyroid which varies according to the iodized status. The aim was to describe the clinical, etiology and therapeutic profile of dysthyroidism in elderly subjects in the internal medicine at the Abass Ndao University Hospital. Patients and methods: This was a retrospective, descriptive and analytical study, including all subjects aged 60 and over followed from January 1, 2010 to December 31, 2019 (10 years) for thyroid disease. Results: 371 Patients were collected with a prevalence of 3.8%. The sex ratio was 0.15 and the mean age was 65.3 years. The circumstances of discovery of the disease were a grade 2 - 3 goiter (62.5%), exophthalmos (24.5%), thyrotoxicosis (56.6%), a symptom of low metabolism (5.4%), a cervical compression (10.8% including 8% of dysphasia), and a cardiothyreosis (9.4%). It was hyperthyroidism (65.2%), and hypothyroidism (7.2%). The main etiologies were toxic multinodular goiter (33.2%), Graves’s disease (29.6%), euthyroidism nodular goiter (26.8%), toxic adenoma (2.4%), and Hashimoto’s thyroiditis (6.7%). The compressive manifestations were exclusive of nodular goiter. Among the 35 cases of cardiothyreosis, there was a rhythm and conduction disorder in 25 cases (6.7%) and the underlying thyreopathy was a toxic nodular goiter in 57.1%. Thyroidectomy involved 44.7% of patients, including 32.6% of Graves’ disease, 48.3% of toxic nodular goiter, and 61.8% of nodular goiter in euthyroidism. We found 02 cases of papillary carcinomas on multinodular goiter. Conclusion: In our hospital series, there is variability in the clinical manifestations of dysthyroidism in the elderly. Complications, mainly cardiac and compressive, remain a major reason for consultation. Toxic nodular goiter is preponderant and its management, especially radical, must be multidisciplinary and according to the profile.

甲状腺相关视神经病变的研究进展

甲状腺相关视神经病变是甲状腺相关眼病的继发性病变,临床表现包括视力下降、色觉受损、相对性传入性瞳孔障碍、视盘水肿或萎缩等。眼科辅助检查表现为视野异常和视觉诱发电位异常等,影像学检查显示眶尖拥挤可辅助诊断。目前此病的发病机制未明,既往研究提出其与视神经压迫、牵拉和缺血有关。治疗方法包括大剂量糖皮质激素静脉冲击治疗、眼眶减压手术、眼眶放射治疗和生物制剂等。本文主要回顾流行病学特征、发病机制及临床诊治等方面的进展,以期为临床实践和研究提供参考。

The effect of orbital radiation therapy on thyroid-associated orbitopathy complicated with dysthyroid optic neuropathy

Thyroid-associated orbitopathy （TAO） is an inflammatory autoimmune disorder. The most serious complication of TAO is dysthyroid optic neuropathy （DON）, which can lead to permanent vision loss because of volume expansion in the orbital apex. Orbital radiation therapy （ORT） is an anti-inflammatory treatment used in the treatment of active TAO. Clinical studies support radiotherapy as having a modest effect on DON, and early radiotherapy may protect against disease progression to DON. Current studies suggest that radiotherapy is generally safe. However, risks still exist in some cases. The possible effects of radiotherapy on TAO, especially complicated with DON, are reviewed. The effects of radiotherapy on DON are not completely known, and evidence from standardized, prospective, and multicenter clinical trials is still lacking.

Modified endoscopic transnasal orbital apex decompression in dysthyroid optic neuropathy

Background:To describe the surgical technique and assess the clinical efficacy and safety of modified endoscopic transnasal orbital apex decompression in the treatment of dysthyroid optic neuropathy.Methods:In this retrospective research,forty-two subjects(74 orbits)who underwent modified endoscopic transnasal orbital apex decompression for the treatment of dysthyroid optic neuropathy were enrolled.Preoperative and postoperative best-corrected visual acuity(BCVA),visual field mean deviation(MD),Hertel exophthalmometry,and new onset diplopia were assessed before and after the intervention.The Wilcoxon test was used for differential analysis.Linear mixed-models’analyses were conducted to assess the potential predictors for BCVA change.Results:Postoperatively,the mean BCVA improved from 0.70±0.62 logMAR to 0.22±0.33 logMAR.BCVA significantly improved in 69 eyes(93%),remained stable in 4 eyes(5%)and deteriorated in 1 eye(1%).MD of visual fields improved from−13.73±9.22 dB to−7.23±7.04 dB.Proptosis decreased from 19.57±3.38mm to 16.35±3.01mm.Preoperative BCVA,MD of visual fields and medical rectus diameter were independent factors associated with improvements in BCVA(P<0.05)by linear mixed-models’analyses.Eighteen patients(42.9%)developed new diplopia postoperatively.Conclusion:Modified endoscopic transnasal orbital apex decompression effectively restores vision in dysthyroid optic neuropathy.

甲状腺相关性眼病MRI研究现状及进展

甲状腺相关性眼病(thyroid-associated ophthalmopathy,TAO)是一种自身免疫性疾病,其发病率居成人眼眶疾病首位。临床上主要根据临床活动度评分(clinical activity score,CAS)将TAO患者分为活动期和非活动期。TAO活动性的判断对于治疗方案的选择至关重要,但CAS受临床医生经验及患者主诉的影响。磁共振成像(magnetic resonance imaging,MRI)不仅能够提供眼眶各结构的解剖学信息,而且通过在各序列上进行定量评价,可以分析各结构的病理改变。MRI常规形态学序列(T1WI、T2WI)、磁共振功能成像(扩散加权成像、扩散张量成像)、磁共振定量分析技术(T1 mapping、T2 mapping)、化学位移成像技术(水脂分离成像技术、非对称回波的最小二乘估算法迭代水脂分离技术)及放射组学在TAO的活动性、严重程度、并发症发生以及治疗反应性等方面发挥了重要作用。本文通过对这些技术在TAO患者的受累结构(眼外肌、视神经、泪腺及眶后脂肪)中的应用研究进行综述,有望提示多序列、多参数MRI对TAO临床管理的重要价值,并指导临床上治疗方案的选择。

甲状腺功能障碍性视神经病变的视觉功能改变及早期诊断指标的ROC曲线分析

目的:甲状腺功能障碍性视神经病变(dysthyroid optic neuropathy,DON)严重危害甲状腺相关眼病患者视力。本研究观察DON患者的视觉功能改变,并评价DON检测指标的诊断价值。方法:回顾性分析2017年1月至2019年12月在中南大学湘雅医院就诊的49例DON患者(98眼)的临床资料。所有患者均行最佳矫正视力(best corrected visual acuity,BCVA)、Humphrey视野、视觉诱发电位(visual evoked potential,VEP)和对比敏感度检测。将98眼分为DON组(45眼)和非DON组(53眼)。采用t检验比较2组患者上述各项检测的相关指标,受试者操作特征(receiver operating characteristic,ROC)曲线分析各指标的敏感度和特异度。结果:DON组的BCVA和视野指数(visual field index,VFI)均显著低于非DON组(均P<0.05),平均缺损(mean deviation,MD)和模式标准偏差(pattern standard deviation,PSD)均显著高于非DON组(均P<0.05)。DON组的低频对比敏感度(low frequency contrast sensitivity,CSL)、中频对比敏感度(medium frequency contrast sensitivity,CSM)、高频对比敏感度(high frequency contrast sensitivity,CSH)均明显低于非DON组(均P<0.05),CSH尤为明显。在15°、30°和60°空间频率时,与非DON组比较,DON组的N135波幅显著降低,N75波、P100波、N135波的潜伏期显著延长(均P<0.05);在15°和30°空间频率时,DON组较非DON组P100波幅明显降低(均P<0.05)。ROC曲线分析结果显示:VFI、CSL、CSM、CSH和15°P100波幅诊断DON的曲线下面积(area under the curve,AUC)分别为0.812、0.841、0.880、0.784和0.791,以CSM的敏感度和特异度最高。结论:DON患者的视觉功能均存在不同程度的受损。VFI、CSL、CSM、CSH和15°P100波幅可能成为早期诊断DON的有效指标。

The effect of intravenous high-dose glucocorticoids and orbital decompression surgery on sight-threatening thyroid-associated ophthalmopathy

AIM: To report the effects of intravenous high-dose glucocorticoids(iv GC) and orbital decompression(OD) surgery for treatment of sight-threatening thyroid-associated ophthalmopathy(TAO).METHODS: A retrospective review of medical records from patients with sight-threatening TAO [definite or highly suspected dysthyroid optic neuropathy(DON)] treated with iv GC(60 cases) and OD(25 cases) was conducted at the Zhongshan Ophthalmic Center between January 2001 and January 2009. Patients were initially treated with iv GC(iv GC group). If no significant improvement in visual function was obtained, they then received OD surgery(OD group). The pre-versus post-treatment efficacies of either iv GC or OD in these patients were assessed using several indices, including visual acuity, intraocular pressure, ocular alignment, ocular motility, and exophthalmos. RESULTS: Nighty-one eyes had definite DON while 79 were considered to have highly suspected DON. In the iv GC group, 51 individuals(85.0%) eventually demonstrated normal vision, while 10 patients(16.7%) demonstrated a reduction in deviation(P<0.01), and 35 cases(58.3%) showed slight improvements in ocular motility(P<0.01). In OD group, visual acuity improved in 24 cases(96.0%, P<0.01) and all patients showed varying reductions of exophthalmos(mean: 4.35±1.13 mm, P<0.01). Eight cases(32.0%) experienced an 8-15 PD reduction of deviation and ocular motility improved in 12 cases(48.0%), while 3 patients(12.0%) developed new-onset strabismus with diplopia post-surgically(P<0.01). Patients were followed up at an average of 1.55±1.07 y. CONCLUSION: Both iv GC and OD show good therapeutic efficacy in the treatment of sight-threatening TAO. Thepresence of extremely poor eyesight(≥0.5 log MAR) was corrected in some patients with iv GC alone, thus sparing these patients from subsequent OD surgery. In patients who were refractory to steroids, subsequent OD surgery often provided satisfactory outcomes, however, new-onset strabismus with diplopia was observed in 12.0% of these cases.

Orbital decompression surgery for the treatment of Graves＇ ophthalmopathy：comparison of different techniques and long-term results

AIM： To evaluate the long-term results of different orbital decompression techniques performed in patients with Graves＇ ophthalmopathy（GO）.METHODS： Totally 170 cases with GO underwent orbital decompression between 1994 and 2014. Patients were divided into 4 groups as medial-inferior, mediallateral（balanced）, medial-lateral-inferior, and lateral only according to the applied surgical technique. Surgical indications, regression degrees on Hertel exophthalmometer, new-onset diplopia in the primary gaze and new-onset gaze-evoked diplopia after surgery and visual acuity in cases with dysthyroid optic neuropathy（DON） were compared between different surgical techniques.RESULTS： The study included 248 eyes of 149 patients. The mean age for surgery was 42.3±13.2 y. DON was the surgical indication in 36.6% of cases, and three-wall decompression was the most preferred technique in these cases. All types of surgery significantly decrease the Hertel values（P〈0.005）. Balanced medial-lateral, and only lateral wall decompression caused the lowest rate of postoperative new-onset diplopia in primary gaze. The improvement of visual acuity in patients with DON did not significantly differ between the groups（P=0.181）. CONCLUSION： The study show that orbital decompression surgery has safe and effective long term results for functional and cosmetic rehabilitation of GO. It significantly reduces Hertel measurements in disfiguring proptosis and improves visual functions especially in DON cases.

甲状腺功能障碍性视神经病变的影像学研究进展

甲状腺功能障碍性视神经病变(DON)是甲状腺相关眼病(TAO)引起视神经功能损害的严重并发症,主要由眶内肿胀的眼外肌压迫眶尖视神经所致。早期诊治对疾病的疗效和预后至关重要。眼眶影像学检查在DON的诊断和评估上发挥着重要的作用,可以显示眼眶组织解剖结构,评估疾病分期及疗效,还能帮助识别倾向于发展为DON的患者。本文回顾了DON的病因、临床特征和影像学,着重对DON的影像学研究进行综述,包括CT、MRI和多普勒超声研究。

基于低频振幅算法的甲状腺相关性眼病视神经病变自发脑活动研究

目的:基于静息态功能磁共振低频振幅(ALFF)算法,对比观察甲状腺相关性眼病(TAO)伴或不伴视神经病变(DON)时静息状态下脑自发神经活动的改变。方法:纳入26例TAO不伴DON患者、18例TAO伴DON患者。对所有被试行全脑静息态功能磁共振及T 1结构像数据采集。采用ALFF算法分析两组患者脑区活动差异。结果:与TAO不伴DON组比较,DON组右颞中回、右中央前回、右顶上小叶ALFF值增加,左额上回ALFF值降低,差异均具有统计学意义(P<0.05,AlphaSim校正)。结论:基于低频振幅的静息态磁共振分析可以反映TAO伴或不伴DON时自发脑部活动脑区异常表现。这些结果对于DON视功能损伤致病机制模型研究和提出新的治疗方法都有重要启发。

甲状腺相关视神经病变的回顾性临床横断面研究

目的明确甲状腺相关视神经病变(DON)的临床特征,为早期诊断和治疗提供依据。方法回顾性分析2015年1月至2017年12月我院收治的DON患者98例196只眼首次就诊的临床资料,包括一般资料和甲状腺功能状态、眼科检查、影像学检查等资料。结合相关文献对所有眼进行判断,可判定为确诊、可疑和排除,将确诊或可疑DON眼纳入研究。结果 98例DON患者中男性59例、女性39例(男女比例为1.51∶1),年龄为34~74(52.51±10.25)岁,均有(被动)吸烟史,96例有甲状腺功能亢进症。确诊DON患者为80例、可疑为18例,确诊122只眼、可疑56只眼、排除18只眼。98例患者的临床活动度评分为(4.44±1.53)分,其中30例≤3分。178只确诊和可疑DON眼中最佳矫正视力≤0.6者有142只,色觉减退130只,视盘水肿38只,视盘苍白56只,视盘正常84只;18只非DON眼中17只视盘正常。眼球突出度≤21 mm的确诊DON眼有38只。影像学检查显示80例确诊DON的患者均有眶尖拥挤综合征,其中双侧67例(83.75%)、单侧13例(16.25%)。结论中老年、男性、吸烟史和甲状腺功能亢进是DON的危险因素。眶尖拥挤综合征是DON最主要的病理基础。视力损害、色觉减退和视盘水肿或苍白是DON最具特征性的临床征象。

甲状腺相关性眼病脑功能性磁共振成像及面孔识别能力改变的研究

目的 应用脑功能性磁共振成像(fMRI)及面孔判断程序测试分析甲状腺相关性眼病(TAO)患者大脑结构和功能的改变及面孔识别能力的改变.方法 选取符合标准的TAO患者63例,根据视神经是否受损分成视神经损伤组(DON)和非视神经损伤组(NDON),应用脑功能性磁共振成像及面孔判断程序测试检查,应用体素形态学分析技术(VBM)比较两组患者脑灰质密度以及面孔识别能力的改变.结果 VBM结果显示DON组患者左侧枕上叶、左侧枕中叶、双侧颞下回区域,以及右侧前扣带回区域、右侧梭状回区域脑灰质密度下降(P<0.001).将非面孔、低相似度、高相似度、面孔图像判定为面孔的概率,DON组分别为0.028、0.062、0.167、0.697,NDON组为0.007、0.047、0.124、0.765,DON组患者的面孔识别概率较低(P<0.05).左侧枕上叶灰质密度与右眼和左眼的最佳矫正视力分别存在正相关性(r1=0.435、P1=0.004,r2=0.532,P2=0.000).左侧枕中叶灰质密度与右眼和左眼的最佳矫正视力存在正相关性(r3=0.393、P3=0.009,r4=0.369,P4=0.015).结论 DON患者不仅存在视神经的损害,还有多个区域的脑灰质密度的下降.左侧枕上叶、枕中叶灰质密度与最佳矫正视力成正相关性,提示DON的发病可能与甲状腺激素水平减低有关,同时影响中枢神经系统.

鼻内镜下总腱环区域减压治疗甲状腺相关眼病视神经病变的疗效分析

目的评估鼻内镜下总腱环(annulus of zinn,AZ)区域减压作为难治性甲状腺相关眼病视神经病变(dysthyroid optic neuropathy,DON)手术治疗方案的早期疗效及安全性,并初步分析术后视功能转归的影响因素。方法回顾性纳入2021年7月至2023年1月于北京大学第三医院接受鼻内镜下AZ区域减压的DON患者35例(56眼),年龄(52.2±12.0)岁,男性9例(13眼),女性26例(43眼)。其中接受单纯经鼻内镜内、下壁(以下简称2壁)眶减压35眼,鼻内镜联合经眶入路深外壁减压的内、外和下壁(以下简称3壁)眶减压21眼,记录治疗前后的最佳矫正视力(best corrected visual acuity,BCVA)、视野(MD值)、眼球突出度(突眼度)、眼压等指标,同时记录不良反应及其发生率,以手术后1个月的复查结果作为治疗后数据。统计学分析采用配对t检验和Spearman相关分析法。结果患者术后BCVA、视野、眼压及突眼度明显改善,手术前后相比,差异有统计学意义(t值分别为8.37、6.17、4.50和9.20,P值均<0.001)。3壁眶减压组突眼度变化差值大于2壁眶减压组,差异有统计学意义(t=-2.82,P=0.007);BCVA、视野和眼压手术前后变化差值3壁眶减压组有大于2壁眶减压组的趋势,但差异无统计学意义(P值均>0.05)。术后视力差值和视野差值与术前视力、术前视野呈正相关(P值均<0.001);术后眼压差值和突眼度差值与术前眼压、术前突眼度呈正相关(P值均<0.001)。术前复视患者7例(20.0%),术后新增复视患者2例(5.7%)且于术后3个月内恢复。结论鼻内镜下AZ区域减压是安全、有效的治疗难治性DON的手术方式,BCVA改善明显。AZ区域减压结合联合入路3壁眶减压可更好地改善眼球突出度。

甲状腺相关眼病性视神经病变42例分析

目的观察甲状腺相关眼病（TAO）性视神经病变（dysthyroid optic neuropathy，DON）的临床治疗效果。方法回顾分析2009年至2013年在云南省第二人民医院眼科收治的42例DON患者60只眼的临床资料，并对比其在激素治疗、开眶减压手术治疗前后的疗效。结果研究治疗前患者最佳矫正视力平均为0．25，治疗后患者最佳矫正视力平均为0．6（P〈0．05）；治疗前视野异常的患者为51只眼（86．67％，51／60），治疗后视野异常的患者为7只眼（11．67％，7／60）（P〈0．05）；其余指标如眼压、眶压、眼球突出度、眼肌、眼底等前后对比均有明显改善；激素治疗中18例治疗1个疗程，占42．9％（18／42）；15例治疗2个疗程，占35．7％（15／42）；9例治疗3个疗程，占21．4％（9／42）。26例36只眼行眼眶2-4壁的开眶减压手术，手术后1个月33只眼视力均有不同程度的提高（P〈0．05）；3只眼无提高。且与激素治疗组相比，行开眶减压手术患者视力提高较明显，差异有统计学意义（P〈0．05）。结论DON可有视力、视野、VEP、眶压、眼压、眼底、眼肌等异常；甲泼尼龙和开眶减压手术是治疗DON的有效方法。

内窥镜眶减压术治疗甲状腺功能障碍性视神经病变

目的评价内窥镜眶减压术治疗甲状腺功能障碍性视神经病变的临床效果。方法回顾性研究2012年2月到2015年11月确诊为甲状腺功能障碍性视神经病变26例（45只眼），均行内窥镜经鼻眶减压术，观察手术前后视力、眼压、眼球突出度、眼球运动、复视检查、色觉及视野等检查结果。结果内窥镜经鼻眶减压术后，全组45只眼（100％）最佳矫正视力均有提高，无视力下降者。术前最佳矫正视力为光感-0．4者42只眼（93．33％），术后最佳矫正视力为0．5～1．5者41只眼（91．11％）。眼球突出度及眼压均较术前明显降低，6例（23．08％）出现内斜或原有内斜角度增大。无术中术后并发症发生。结论内窥镜经鼻眶减压术安全、有效、微创，无头面部瘢痕，是甲状腺功能障碍性视神经病变良好的手术方法。

威胁视力的Graves眼病的诊治

威胁视力的Graves眼病(Graves’ophthalmopathy,GO)包括甲状腺功能障碍性视神经病变(dysthyroid optic neuropathy,DON)和暴露性角膜炎,是GO的急症,严重者失明,需要紧急干预治疗。应早期识别及时诊断DON。大剂量糖皮质激素静脉冲击治疗仍是DON患者首选方案,无改善者行眶减压术。糖皮质激素联合球后放射治疗或其他免疫抑制剂旨在减少激素用量提高疗效仍需大样本随机对照的临床试验;新型生物制剂如IGF-1R单抗IL-6受体单抗在威胁视力的GO中的应用仍在探索中。

最大化眼眶减压手术和糖皮质激素冲击治疗甲状腺相关眼病视神经病变的疗效观察

目的评估最大化眼眶减压手术和糖皮质激素冲击治疗作为甲状腺相关眼病视神经病变(DON)初始治疗方案的疗效及安全性。方法回顾性队列研究。收集2019年4月至2021年11月在北京大学人民医院诊治的43例(66只眼)DON患者资料,根据治疗方法分为激素组(21例,33只眼)和手术组(22例,33只眼)。激素组接受了总剂量7.5 g的糖皮质激素静脉冲击治疗;手术组接受了最大化眼眶减压手术治疗。记录治疗前后的最佳矫正视力(最小分辨角对数视力)、临床活动性评分(CAS)、视觉诱发电位(VEP)-P_(100)振幅和潜伏期、肌肉指数(MI)、眼球突出度等指标,同时记录不良反应及其发生率;以手术后或糖皮质激素冲击治疗后6个月的复查结果作为治疗后数据。统计学分析主要采用Wilcoxon符号秩检验、配对及独立样本t检验、Mann-Whitney U检验和χ^(2)检验;非正态分布数据以M(IQR)表示。结果2个组患者性别、年龄、病程、眼别分布及治疗前最佳矫正视力、CAS、VEP-P_(100)振幅和潜伏期、MI等基线数据差异均无统计学意义(均P>0.05)。治疗后,激素组的最佳矫正视力从1.00(0.65)改善至0.70(0.60)(Z=-4.55),手术组从1.00(0.95)改善至0.60(0.55)(Z=-4.87);激素组CAS从5(2)分降至2(2)分(Z=-4.91),手术组从5(2)分降至为2(2)分(Z=-4.94);激素组VEP-P_(100)波的振幅从(3.49±1.34)μV提高至(5.26±2.00)μV(t=-9.08),潜伏期从(110.52±12.11)ms缩短至(103.53±6.67)ms(t=4.67);手术组振幅从(3.21±1.74)μV提高至(4.78±2.36)μV(t=-9.24),潜伏期从(118.48±20.16)ms缩短至(106.45±10.57)ms(t=2.84);组内治疗后与治疗前比较差异均有统计学意义(均P<0.001);而治疗后2个组间比较差异均无统计学意义(均P>0.05)。治疗后,激素组和手术组的眶尖拥挤缓解(MI≤0.52)率为分别为64%(21/33)和91%(30/33),眼球突出度下降≥2 mm的比例分别为64%(21/33)和94%(31/33),手术组均高于激素组,差异均有统计学意义(χ^(2)=5.52、7.34,均P<0.05)。2个组均未出现严重不良反应或并发症,激素组与治疗组轻度不良反应发生率分别为38%(8/21)与59%(13/22),差异无统计学意义(P>0.05)。结论最大化眼眶减压手术和糖皮质激素冲击治疗均能有效改善DON患者的视功能、降低CAS。两种治疗方法均具有较高的安全性,并且在缓解眶尖拥挤和眼球突出方面,手术更具优势。