眼眶减压术后新发复视的研究进展

来源期刊：眼科学报 | 2023年9月第38卷第9期： 624-632 发布时间：收稿时间：2024/1/5 16:32:56 阅读量：3571

作者：: 周朝纳,

刘桂琴,

关键词：: 甲状腺相关眼病眼眶减压术复视; thyroid-associated ophthalmopathy TAO orbital decompression diplopia

DOI：: 10.12419/2307030004

收稿时间：
修订日期：
接收日期：

甲状腺相关眼病(thyroid-associated ophthalmopathy,TAO)，又称Graves眼病，是与甲状腺疾病密切相关的一种器官特异性自身免疫性疾病。眼球突出是TAO的主要临床表现之一，也是临床上多数患者就诊的原因。眼球突出一方面会影响美观，另一方面可因眼睑闭合不全导致暴露性角膜炎或因眼眶压力增大导致压迫性视神经病变。眼眶减压术用于重度TAO已有过百年历史，从最早经外眦皮肤切开的传统外部切口入路进行骨性眼眶减压及脂肪减压到内镜下经鼻入路眼眶减压术，其安全性和有效性均已得到肯定。术后复视是眼眶减压术常见的并发症。近年来，随着眼眶减压术的发展，其越来越多地用于美容目的以矫正眼球突出。然而术后的新发复视仍然是困扰众多相关眼科医疗工作者的难题。近年来，多项研究对术后新发复视的相关因素进行了探讨，并由此对眼眶减压术进行改良，在对术后新发复视的减少方面取得不同程度的进展。该文对眼眶减压术后新发复视的研究进展进行综述，旨在促进专科医生更精准地开展TAO的手术，进而提高手术患者术后的生活质量及手术满意度。

甲状腺相关眼病(thyroid-associated ophthalmopathy, TAO)，是一种与甲状腺疾病尤其是自身免疫性甲状腺疾病密切相关的器官特异性自身免疫性疾病，位居成人眼眶疾病发病率首位^[1]。TAO患者典型的眼部症状包括眼睑退缩、眼球突出、眶周水肿、斜视、复视等，严重者可能因眼睑闭合不全出现暴露性角膜炎和(或)因眼眶压力的增大而导致压迫性视神经病变，二者都具有致盲性。其中眼球突出多表现于双眼，是临床上多数患者就诊的原因。眼眶减压术用于治疗重度TAO已有过百年历史。从最早Dollinger报道的从外眦皮肤切开的传统外部切口入路进行骨性眼眶减压及脂肪减压，到1990年Kennedy首创内镜下经鼻入路眼眶减压术，眼眶减压术在不断地发展和完善。近年来，仅用于减少眼球突出度的美容性眼眶减压术的占比越来越高，且在不同的随访报道中显示其治疗TAO患者眼球突出的安全性及有效性^[2-7]。眼眶减压术是通过去除眼眶骨壁和(或)减少眶内脂肪从而矫正失衡的骨性眼眶容积-眼眶软组织体积关系的方式治疗TAO性眼球突出。其去除不同的眶壁及不同数目的眶壁对眼球突出具有不同的贡献：据回顾性研究，仅外侧壁、内壁、下-内壁、外-内壁、三壁减压可使眼球突出回缩分别为：2~3 mm、2~4 mm、4~6 mm、4~5 mm及8 mm，四壁减压甚至可以实现12~14 mm的回缩^[8-9]。在Cheng等^[3]的报道中，平均切除眼眶脂肪体积4.4 mL，眼球突出度减少4.1 mm。(见表1)脂肪减压常与骨性减压联合以取得更好的治疗效果^[5,10]，外-内壁减压联合脂肪减压可以达到三壁减压的眼球回缩效果^[11]。术后复视是眼眶减压术常见的并发症，在各报道中，眼眶减压术后出现的新发复视率可达38%(脂肪减压术)、51%(骨性减压术)左右^[12]。眼眶减压术后新发复视的产生与眼眶结构和功能的改变以及减压的术式有关，现将近年相关研究进展综述报道如下。

表1 不同类型眼眶减压术后眼球回缩量

Table 1 The amount of eyeball retraction after different types of orbital decompression surgery

1 眶减压术后与新发复视有关的眼眶结构和功能变化

1.1 眼球丧失前内侧骨膜和眶骨的支撑

骨性眼眶下内侧的Strut结构，又称筛-上颌骨支撑结构。其前部由厚的上颌骨组成，可为眼眶下缘提供支撑，中部由筛骨和眶底薄的上颌骨交界处形成，后方由筛窦和腭骨的眶突交界处形成。前部Strut结构不仅为眼球提供了重要的骨性支撑，还为支持眼球的前部眶周韧带提供了骨性附着点^[13]。眼眶减压术中有意或无意去除Strut结构可导致严重的垂直复视和日落综合征^[14]。

1.2 Pulley结构改变

眼外肌Pulley是由胶原纤维、弹性纤维和平滑肌形成并包绕在眼外肌周围的环状结构，其主要功能是改变眼外肌肌力的作用方向^[15]。Pulley结构与眼眶壁相连，直肌从Zinn环起始向前穿过Pulley后附着于巩膜。其作为眼外肌的功能性起点，在眼球运动时与眼眶位置通常固定，在维持空间关系、限制偏移和抵抗位移上起到至关重要的作用，从而使眼球在运动期间位置协调^[16]。Pulley结构不稳定与眼球转动时明显增加的眼球移位有关，其异常与许多类型斜视的发生相关^[17]。有研究指出，球后脂肪能起到旋转眼的轴承作用，使眼直肌腹保持在适当的位置，而这种脂肪由结缔组织片包裹^[18]。目前缺乏眼眶减压术后Pulley结构改变的研究报道。

1.3 肿胀的眼外肌与收缩力的变化

眼眶减压术会加重已纤维化眼外肌的收缩力，使眼球转位加重^[19]。有研究者发现，术后内斜视的患者会出现内直肌增厚而非移位，并且收缩力有所增加^[20]。通过电子计算机断层扫描(computed tomography, CT)对眼外肌的测量，发现眼眶减压术后早期，眼外肌体积有一定的增加，而术后20周时眼外肌体积缩小^[21]。Hu等^[22]的研究发现，眼眶减压术后内直肌体积比术前增加了27%，外直肌、上直肌/上睑提肌复合体、下直肌和上斜肌在术后则未见明显的体积增加。Gupta等^[23]发现，平衡减压术(深外壁联合内壁减压)后，外直肌的宽度比内直肌的宽度增加得更多。关于术后眼外肌体积增大的原因，许多学者有不同的看法，如术后炎症反应致使的眼外肌增厚、眼眶压力突然改变导致肌肉在高渗状态下扩张、静脉充血以及术前相对处于拉伸状态的肌腹在术后得到放松等^[23-26]。

1.4 眼外肌的移位

减压手术后，眼外肌移位到相邻的鼻窦会导致或加剧肌肉的失衡。去除内壁后，内直肌可在眶尖附近以锐角进入筛窦^[27]，这种肌肉路径的离心位移可使肌力增加从而导致术后复视。内直肌向筛窦位移的程度与外展范围呈负相关，与水平复视的严重程度直接相关^[28]。术后水平复视常归因于内直肌的异常，下壁减压术后下直肌脱垂到上颌窦可导致垂直凝视受限^[28]。

1.5 TAO术后再激活

TAO的发病机制尚未完全明确，免疫、遗传、环境等因素均可能与其有关。研究表明，细胞免疫反应可产生不同细胞因子，同时辅助活化体液免疫反应，体液免疫反应产生的自身抗体攻击免疫眼眶成纤维细胞。眼眶成纤维细胞可分泌炎症细胞因子和透明质酸等，导致眶脂肪体积的增大及眼外肌的肥大。在体液免疫方面，自身抗原促甲状腺激素受体(thyroid stimulating hormone receptor,TSHR)及胰岛素样生长因子-1受体(insulin-like growth factor-1 receptor,IGF-1R)均可通过介导相关的信号转导通路使透明质酸大量分泌。环境中的危险因素，如吸烟、甲状腺功能异常、硒元素的缺乏、较高的压力或应激水平可增强细胞免疫效应或激活眼眶成纤维细胞从而导致TAO^[30-34]。TAO的经典病程是持续6~24个月的活跃炎症期，随后则是慢性纤维化阶段，但也有TAO在一段时期的静止后重新激活^[35]。Baldeschi等^[36]报告的康复性骨眼眶减压术后TAO重新激活现象的发生率为1.3%(3/239)，Woo等^[37]报告了7.6%(7/92)患者在骨性减压联合脂肪减压术约36周后发生TAO的重新激活，该报道指出吸烟及术前限制性肌病的程度或与TAO的再激活有关。

1.6 术后粘连与瘢痕形成

眼眶减压术后眼外肌周围的粘连和瘢痕的形成、眼外肌以外的眶内组织粘连也可能是术后新发复视的原因之一^[20,38-41]，患者通常需要在减压术后的第一天进行眼球运动以防止这种情况的发生^[42]。Golan等^[43]的研究中，尽管术后没有在高分辨率磁共振成像(magnetic resonance imaging,MRI)上找到局灶性的瘢痕带，但随后的手术中却能在原来的手术区域找到瘢痕带。眼眶脂肪似乎在术后粘连中发挥着一定的作用，有研究者认为经睑入路可能会破坏更多的眼眶脂肪室从而引起眼外肌更多的粘连及纤维化^[41]，而将保留的一些眶脂肪轻挤到脂肪去除完毕的部位则可以减少眼外肌与眶周之间的粘连及消除无效腔^[44]。也有研究者认为沿内直肌保留骨膜瓣可以防止其在筛窦与骨骼裸露的表面黏附^[45]。此外，术中对神经及软组织损伤也与眼眶减压术后新发复视有关^[46-48]。

2 术后新发复视率较低的眼眶减压术式

目前，深外侧壁减压术及平衡减压术被认为是术后新发复视率较低的术式。

2.1 深外壁减压术

1911年Dollinger首次描述了去除外侧壁的眶减压，随后Goldberg等提出了对外侧壁的更进一步的减压，称为深外侧壁减压^[49-50]。深外壁由蝶骨的大部分组成，此区域的减压包括泪腺窝、蝶骨门框和眶下裂盆。深外壁减压去除的骨性结构几乎位于肌锥的后方，外直肌在外侧壁减压后疝入骨缺损处所引起的肌锥移位也不如内直肌的移位大^[51]。与内侧壁减压及平衡减压术相比，深外壁减压后的新发复视率更低^{[11,50, 52-54]}。 Baldeschie等^[49]报告，深外壁新发复视的发生率为13%，并能在4~6个月内自发消退。深外壁减压术后可能会出现眶周肌与颞肌附着导致的咀嚼时的振动视^[55]，在颞肌内侧留下一层薄骨则可减轻这种症状^[51]。由于进行性颞肌和皮下脂肪的萎缩，术后可能出现颞骨空洞，保留一定的眶缘可以减少其发生，同时也可以通过脂肪移植来纠正^[56]。与手术相关的并发症还有颞部感觉的改变、脑脊液漏、持续性三叉神经过敏等^[51-52]。

2.2 平衡减压术

平衡减压术是对眼眶内壁及外壁行骨性减压手术，于1989年由Leone等^[57]首次报道。Shepard等^[58]的研究表明，平衡减压可减少眼球移位及复视的发生概率。该手术方式是使用内镜或经肉眼方法实现内侧壁减压术，而外侧壁的入路则是在眶周皮肤皱纹处做一个大约1.5 cm的外眦切口，暴露眶外侧壁的眶缘后，使用电锯进行上下水平截骨术或保留眶缘，通过磨除眶外侧壁骨质以及去除蝶骨髓质间隙来进一步扩大眼眶体积^{[26, 59-60]}。有学者从发际线入路使用内镜对眼眶进行外壁及内壁的减压手术，以尽可能地减少面部手术瘢痕^[61]。平衡减压可使眼眶组织均衡地向左右释放，这可以避免因单壁减压或不对称眶壁切除引起的眼外肌运动不平衡及复视。平衡减压术后的新发复视率在0~53%^{[36, 62-66]}，其中Shepard^[58]等报道的美容性或暴露性角膜炎的患者没有出现新发复视，Baril等^[63]报道TAO压迫性视神经病变的患者术后新发复视率为52.94%(18/34)。平衡减压的并发症除复视外还包含了眶内壁及眶外壁减压的一系列并发症，如蝶腭动脉分支受损所致的严重术后出血^[41]、误伤硬脑膜所致的硬膜外血肿或脑脊液漏^[67]、术后眶周肌与颞肌附着导致的与咀嚼相关的振动视^[55]、术后太阳穴痛及“咔嗒”感等^[68]。

3 降低眶减压术后新发复视率的措施

许多学者试图通过改良手术细节来降低眼眶减压术后的新发复视率(表 2)。

表2 能减少新发复视发生率的手术方式或技巧及其新发复视率

Table 2 Surgical methods or techniques that can reduce the incidence of new diplopia and their incidence of new diplopia

3.1 保留眼眶Strut结构

保留上颌-筛窦交界处的骨支柱，即Strut结构，可以减少肌锥和眼眶结缔组织向上颌窦和筛窦移位^[69-73]。此术式首先在1992年由Goldberg在经结膜入路的眶减压中提出，随后Wright等将其转化为内镜入路的技术^[74-75]。保留这样一个1.5~2.0 cm的三角形支柱结构有一定的技术难度，手术常因为Strut结构的意外断裂而复杂化^{[69, 76]}。 Bleier等^[70]提出内镜下保留Strut结构的可靠方法，报道中100%的病例可保留Strut结构。其手术方式为在上颌窦造口、蝶骨切开和完整的筛窦切除后，暴露眶底的下内侧支柱与眶下神经之间的骨性眶底，使用标准的额窦咬合器械扩大截骨边界。在内侧和下方完成截骨并保留下内侧的Strut结构。未保留Strut结构的传统下内侧眼眶减压后，4.5%的病例眼球和肌锥向内、向下移位^[77]。在Paridaens等^[78]和Bailey等^[79]的研究中，经结膜下内壁减压联合外壁减压后新发复视率为1.8%~12.5%，他们都认为保留Strut结构使得复视率降低。一项回顾性研究表明，保留Strut结构的内镜眶减压术新发复视率为16%(1/6)，术后复视消退率为36%(4/11)^[64]。据Wright等^[69]研究，保留双侧Strut结构患者术后复视的发生率为0(0/6)，尽管一些研究认为Strut结构的保留并不会影响减压的充分性，但仍有另一些研究表明保留Strut结构会造成术后眼球内陷不理想、眼睑闭合欠佳，尤其在眶内软组织广泛纤维化的患者中^{[48, 80-82]}。

3.2 保留眶周带

行内壁骨性减压后内直肌可向筛窦移位，这会使眼外肌失衡进而导致复视^{[28, 83]}。 Metson和Samaha^[29]提出沿内直肌保留前后骨膜作为吊带以稳定内直肌并防止其脱垂，脂肪仍可以在眶周带的上方和下方进入筛窦和上颌窦中，并且不会干扰内镜经鼻进入眶底，该研究中新发复视率为0。其手术方式为内镜经鼻入路完全暴露眶筋膜后在接近内直肌上下边缘的两个相隔约10 mm的水平切口上切开，切口起于蝶骨前表面延伸至上颌线。上、下切口分别平行于筛顶及眶底。从后向前切以防止突出的眶脂肪阻碍手术视野。保留眶周带的眼眶减压在多项研究中显示出较低的术后复视率(0~11.8%)^{[61, 84-85]}。然而保留眶周带是否会限制眼球突出度的减少仍待讨论，Mainville等的研究表明保留眶周带会减少减压手术对减少眼球突出度的效益^[77]。Jimenez-Chobillon等^[84]对比Metson和Schaefer等的报道后认为保留眶周带并不会严重限制眼球突出度的减少。Vaidya等^[86]的研究表明，在平衡减压术中沿内直肌保留骨膜瓣不会使术后双眼单视视野及偏斜角发生改变，眶周带的保留可能无法防止内直肌的移位，但与传统的纵向Ⅰ型骨膜瓣不同，上述研究中所制作的骨膜瓣为U形，其限制内直肌移位能力可能较低^[45]。

3.3 保留前眶周部

眼眶结缔组织间隔在前部眼眶中分布最为广泛和复杂，连接眼外肌并将其连接到眼眶壁^[17]。保留前眶周部可能有助于支撑眶内容物从而降低复视率。有研究将内壁减压骨窗的位置后移，发现比传统中前部骨窗减压更少的眼位偏斜程度^[87]，靠后且面积小的骨窗可避免眼外肌的过度移位。去除的骨窗过前可使前内侧骨膜和眶骨的支撑丧失，这可能会导致眼球和肌肉锥体向内移动。Seiff等^[88]研究中保留了眶前部10~15 mm，而未保留Strut结构，新发复视率为0(0/9)。

4 结语

术后新发复视是眼眶减压术后，尤其是美容性眶减压术后需要面对的头号难题。本文在总结引起术后新发复视相关因素的基础上提出了解决方法。首先，眼眶减压术应尽可能选择在静止期进行，并避免术后眼眶炎症再复发；其次，通过保留具有重要支持和限制作用的眶骨和筋膜来预防眼球和眼外肌向扩大的一侧眶腔过度移位和粘连；第三，尽量抽取肌锥内脂肪，适当保留前部眶周脂肪。对于眶减压术前已存在复视的患者，术后原有复视的进展本文未进行论述，但笔者认为可遵循以下手术方案设计原则来减轻：避免在肥大的眼外肌一侧进行骨壁减压，而选择在其对侧进行骨壁减压；对于两条以上眼外肌肥大者，选择平衡减压术或深外壁减压术。只有不断探索、进一步优化手术技巧才能预防新发复视，提高患者的术后生活质量。

利益冲突

所有作者均声明不存在利益冲突

开放获取声明

本文适用于知识共享许可协议(Creative Commons)，允许第三方用户按照署名(BY)-非商业性使用(NC)-禁止演绎(ND)(CC BY-NC-ND)的方式共享，即允许第三方对本刊发表的文章进行复制、发行、展览、表演、放映、广播或通过信息网络向公众传播，但在这些过程中必须保留作者署名、仅限于非商业性目的、不得进行演绎创作。详情请访问：https://creativecommons.org/licenses/by-nc-nd/4.0/。

1、中华医学会眼科学分会眼整形眼眶病学组, 中华医学会内分泌学分会甲状腺学组. 中国甲状腺相关眼病诊断和治疗指南 (2022年)[ J]. 中华眼科杂志, 2022, 58(9): 646-668.
The Eye Plastic and Orbital Disease Group of the Ophthalmology Branch of the Chinese Medical Association, and the Thyroid Disease Group of the Endocrinology Branch of the Chinese Medical Association. Chinese guideline on the diagnosis and treatment of thyroid-associated ophthalmopathy (2022)[ J]. J Command Contr, 2022, 58(9): 646-668.

2、Gulati S, Ueland HO, Haugen OH, et al. Long-term follow-up of patients with thyroid eye disease treated with endoscopic orbital decompression[ J]. Acta Ophthalmol, 2015, 93(2): 178-183.

3、Cheng AM, Wei YH, Tighe S, et al. Long-term outcomes of orbital fat decompression in Graves' orbitopathy[ J]. Br J Ophthalmol, 2018, 102(1): 69-73.

4、Jernfors%20M%2C%20V%C3%A4lim%C3%A4ki%20MJ%2C%20Set%C3%A4l%C3%A4%20K%2C%20et%20al.%20E%1Bcacy%20and%20safety%20of%20orbital%20%0Adecompression%20in%20treatment%20of%20thyroid-associated%20ophthalmopathy%3A%20%0Along-term%20follow-up%20of%2078%20patients%5B%20J%5D.%20Clin%20Endocrinol%2C%202007%2C%2067(1)%3A%20%0A101-107.

5、Chang M, Baek S, Lee TS. Long-term outcomes of unilateral orbital fat decompression for thyroid eye disease[ J]. Graefes Arch Clin Exp Ophthalmol, 2013, 251(3): 935-939.

6、Li EY, Kwok TY, Cheng AC, et al. Fat-removal orbital decompression for disfiguring proptosis associated with Graves' ophthalmopathy: safety, efficacy and predictability of outcomes[ J]. Int Ophthalmol, 2015, 35(3): 325-329.

7、Po%C5%9Blednik%20KB%2C%20Czerwaty%20K%2C%20Ludwig%20N%2C%20et%20al.%20Treatment%20results%20of%20%0Aendoscopic%20transnasal%20orbital%20decompression%20for%20Graves'%20orbitopathy-a%20%0Asingle-center%20retrospective%20analysis%20in%2028%20orbits%20of%2016%20patients%5B%20J%5D.%20J%20Pers%20%0AMed%2C%202022%2C%2012(10)%3A%201714.

8、Cubuk MO, Konuk O, Unal M. Orbital decompression surgery for the treatment of Graves' ophthalmopathy: comparison of different techniques and long-term results[ J]. Int J Ophthalmol, 2018, 11(8): 1363-1370.

9、Kim JW, Kang SM. Surgical outcomes of endoscopic medial orbital wall decompression[ J]. J Craniofac Surg, 2020, 31(1): 197-200.

10、Wu W, Selva D, Bian Y, et al. Endoscopic medial orbital fat decompression for proptosis in type 1 Graves orbitopathy[ J]. Am J Ophthalmol, 2015, 159(2): 277-284.

11、Unal%20M%2C%20Leri%20F%2C%20Konuk%20O%2C%20et%20al.%20Balanced%20orbital%20decompression%20%0Acombined%20with%20fat%20removal%20in%20Graves%20ophthalmopathy%3A%20do%20we%20really%20%0Aneed%20to%20remove%20the%20third%20wall%3F%5B%20J%5D.%20Ophthalmic%20Plast%20Reconstr%20Surg%2C%20%0A2003%2C%2019(2)%3A%20112-118.

12、Rootman DB. Orbital decompression for thyroid eye disease[ J]. Surv Ophthalmol, 2018, 63(1): 86-104.

13、Kim JW, Goldberg RA, Shorr N. The inferomedial orbital strut: an anatomic and radiographic study[ J]. Ophthalmic Plast Reconstr Surg, 2002, 18(5): 355-364.

14、Yao WC, Sedaghat AR, Yadav P, et al. Orbital decompression in the endoscopic age: the modied inferomedial orbital strut[ J]. Otolaryngol Head Neck Surg, 2016, 154(5): 963-969.

15、钱学翰, 赵堪兴, 李云生, 等. Pulley与经典眼外肌相关结缔组织解剖结构关系的研究[ J]. 解剖学研究, 2004, 26(3): 195-198+201- 245.
Qian XH, Zhao KX, Li YS, et al. Pulley relationship with classic anatomy structure of connective tissue around extraocular muscles in human orbit[ J]. Anat Res, 2004, 26(3): 195-198+201-245.

16、Cornelius CP, Mayer P, Ehrenfeld M, et al. The orbits: anatomical features in view of innovative surgical methods[ J]. Facial Plast Surg, 2014, 30(5): 487-508.

17、李青吉. 眼外肌Pulley的研究进展[ J]. 中国斜视与小儿眼科杂志, 2020, 28(1): 42-44.
Li QJ. Study progress of extraocular muscle pulley[ J]. Chin J Strabismus Pediatr Ophthalmol, 2020, 28(1): 42-44.

18、Simonsz%20HJ.%20Instead%20of%20pulley%20bands%2C%20does%20retrobulbar%20fat%20keep%20the%20eye%20%0Amuscle%20bellies%20in%20place%20and%20thereby%20act%20like%20a%20pulley%3F%5B%20J%5D.%20Strabismus%2C%20%0A2020%2C%2028(2)%3A%20109-113.

19、李燕伟, 杨士强, 张伟, 等. 甲状腺相关眼病眼眶减压术后继发内斜视伴复视的手术疗效观察[ J]. 中华眼科杂志, 2020, 56(3): 183- 188.
Li YW, Yang SQ, Zhang W, et al. The surgical effect of secondary esotropia with diplopia after orbital decompression for thyroidassociated ophthalmopathy[ J]. J Command Contr, 2020, 56(3): 183- 188.

20、Guo J, Li X, Ma R, et al. Correlation between uniocular deviation and duction changes following dierent decompression surgeries in thyroid eye disease[ J]. BMC Ophthalmol, 2021, 21(1): 134.

21、Alsuhaibani AH, Carter KD, Policeni B, et al. Effect of orbital bony decompression for Graves' orbitopathy on the volume of extraocular muscles[ J]. Br J Ophthalmol, 2011, 95(9): 1255-1258.

22、Hu WD, Annunziata CC, Chokthaweesak W, et al. Radiographic analysis of extraocular muscle volumetric changes in thyroid-related orbitopathy following orbital decompression[ J]. Ophthalmic Plast Reconstr Surg, 2010, 26(1): 1-6.

23、Gupta A, Nobori A, Wang Y, et al. Lateral rectus muscle expands more than medial rectus following maximal deep balanced orbital decompression[ J]. Ophthalmic Plast Reconstr Surg, 2018, 34(2): 140- 142.

24、Nishimura K, Takahashi Y, Katahira N, et al. Visual changes after transnasal endoscopic versus transcaruncular medial orbital wall decompression for dysthyroid optic neuropathy[ J]. Auris Nasus Larynx, 2019, 46(6): 876-881.

25、May A, Zubcov A, Fries U, et al. Ancillary procedures in microscopic endonasal orbital decompression for thyroid-associated ophthalmopathy[J]. ORL J Otorhinolaryngol Relat Spec, 2001, 63(3): 137-140.

26、Jefferis JM, Jones RK, Currie ZI, et al. Orbital decompression for thyroid eye disease: methods, outcomes, and complications[ J]. Eye, 2018, 32(3): 626-636.

27、Alsuhaibani AH, Carter KD, Policeni B, et al. Effect of orbital bony decompression for Graves' orbitopathy on the volume of extraocular muscles[ J]. Br J Ophthalmol, 2011, 95(9): 1255-1258.

28、Abràmoff MD, Kalmann R, de Graaf MEL, et al. Rectus extraocular muscle paths and decompression surgery for Graves orbitopathy: mechanism of motility disturbances[ J]. Invest Ophthalmol Vis Sci, 2002, 43(2): 300-307.

29、Metson R, Samaha M. Reduction of diplopia following endoscopic orbital decompression: the orbital sling technique[ J]. Laryngoscope, 2002, 112(10): 1753-1757.

30、Fang S, Zhang S, Huang Y, et al. Evidence for associations between Th1/Th17 “hybrid” phenotype and altered lipometabolism in very severe Graves orbitopathy[ J]. J Clin Endocrinol Metab, 2020, 105(6): dgaa124.

31、Smith TJ, Hegedüs L. Graves' disease[ J]. N Engl J Med, 2016, 375(16): 1552-1565.

32、Lytton SD, Kahaly GJ. Bioassays for TSH-receptor autoantibodies: an update[ J]. Autoimmun Rev, 2010, 10(2): 116-122.

33、Peter HH, Ochs HD, Cunningham-Rundles C, et al. Targeting FcRn for immunomodulation: benets, risks, and practical considerations[ J]. J Allergy Clin Immunol, 2020, 146(3): 479-491.e5.

34、Krieger CC, Neumann S, Gershengorn MC. TSH/IGF1 receptor crosstalk: mechanism and clinical implications[ J]. Pharmacol Ther, 2020, 209: 107502.

35、Bartley GB. Rundle and his curve[ J]. Arch Ophthalmol, 2011, 129(3): 356-358.

36、Baldeschi L, Lupei A, Vu P, et al. Reactivation of Graves' orbitopathy after rehabilitative orbital decompression[ J]. Ophthalmology, 2007, 114(7): 1395-1402.

37、Woo YJ, Kim JW, Yoon JS. Preoperative clinical features of reactivated of Graves' orbitopathy after orbital decompression[ J]. Eye, 2017, 31(4): 643-649.

38、Lee JKS, Hsieh C, Wei YH, et al. The impact of orbital bony or fat decompression on the outcome of strabismus surgery in patients with Graves' ophthalmopathy[ J]. J Formos Med Assoc, 2019, 118(1 Pt 3): 387-394.

39、Cheng AM, Wei YH, Tighe S, et al. Long-term outcomes of orbital fat decompression in Graves' orbitopathy[ J]. Br J Ophthalmol, 2018, 102(1): 69-73.

40、Robert PY, Camezind P, Adenis JP. Orbital fat decompression techniques[ J]. J Fr Ophtalmol, 2004, 27(7):845-850.

41、颜建华, 鲁志卿. 开眶术后斜视的手术治疗[ J]. 中华眼科杂志, 2008, 44(11): 972-975.
Yan JH, Lu ZQ. The surgical management of strabismus following orbitotomy[ J]. J Command Contr, 2008, 44(11): 972-975.

42、Roncevic R , Savkovic Z, Roncevic D. Results of diplopia and strabismus in patients with severe thyroid ophthalmopathy after orbital decompression[ J]. Indian J Ophthalmol, 2014, 62(3): 268-273.

43、Golan S, Gupta A, Goldberg RA. Double vision after minimally invasive orbital decompression[ J]. J Craniofac Surg, 2017, 28(5): e412-e415.

44、Richter DF, Stoff A, Olivari N. Transpalpebral decompression of endocrine ophthalmopathy by intraorbital fat removal (Olivari technique): experience and progression after more than 3000 operations over 20 years[ J]. Plast Reconstr Surg, 2007, 120(1): 109- 123.

45、Takahashi Y, Vaidya A, Yo K, et al. Comparison of degree of medial rectus muscle misalignment after medial orbital wall decompression with or without periosteal flap[ J]. Graefe's Arch Clin Exp Ophthalmol, 2022, 260(3): 1025-1031.

46、Takahashi Y, Kakizaki H. Damage to the inferior oblique muscle branch of the oculomotor nerve: a complication during orbital fat decompression[ J]. Int Ophthalmol, 2019, 39(3): 711-716.

47、Karimi N, Kashkouli MB, Sanjari MS, et al. Inadvertent inferior oblique extirpation during orbital decompression[ J]. Eur J Ophthalmol, 2019, 29(4): NP13-NP15.

48、Parrilla C, Mele DA, Gelli S, et al. Multidisciplinary approach to orbital decompression: A review[ J]. Acta Otorhinolaryngol Italica, 2021, 41(Suppl. 1): S90-S101.

49、Baldeschi L, MacAndie K, Hintschich C, et al. The removal of the deep lateral wall in orbital decompression: its contribution to exophthalmos reduction and inuence on consecutive diplopia[ J]. Am J Ophthalmol, 2005, 140(4): 642-647.

50、Liao SL, Shih MJ, Chang TC, et al. Transforniceal lateral deep bone decompression: a modified technique to prevent postoperative diplopia in patients with disguring exophthalmos due to dysthyroid orbitopathy[ J]. J Formos Med Assoc, 2006, 105(8): 611-616.

51、Ueland%20HO%2C%20Haugen%20OH%2C%20R%C3%B8dahl%20E.%20Temporal%20hollowing%20and%20other%20%0Aadverse%20effects%20after%20lateral%20orbital%20wall%20decompression%5B%20J%5D.%20Acta%20%0AOphthalmol%2C%202016%2C%2094(8)%3A%20793-797.

52、Rajabi MT, Tabary M, Baharnoori S, et al. Orbital anatomical parameters affecting outcome of deep lateral orbital wall decompression[ J]. Eur J Ophthalmol, 2021, 31(4): 2069-2075.

53、Goldberg RA, Perry JD, Hortaleza V, et al. Strabismus after balanced medial plus lateral wall versus lateral wall only orbital decompression for dysthyroid orbitopathy[ J]. Ophthalmic Plast Reconstr Surg, 2000, 16(4): 271-277.

54、Kitaguchi Y, Takahashi Y, Kakizaki H. Computed tomography-based prediction of exophthalmos reduction after deep lateral orbital wall decompression for Graves' orbitopathy[ J]. Albrecht Von Graefes Arch Fur Klin Und Exp Ophthalmol, 2019, 257(12): 2759-2767.

55、Kulker D, Paré A, Louisy A, et al. Management of enophthalmos-related Oscillopsia aer balanced orbital decompression[ J]. J Fr Ophtalmol, 2021, 44(10): e583-e585.

56、Zhang S, Li Y, Wang Y, et al. Comparison of rim-sparing versus rim-removal techniques in deep lateral wall orbital decompression for Graves' orbitopathy[ J]. Int J Oral Maxillofac Surg, 2019, 48(4): 461- 467.

57、Leone CR Jr, Piest KL, Newman R J. Medial and lateral wall decompression for thyroid ophthalmopathy[ J]. Am J Ophthalmol, 1989, 108(2): 160-166.

58、Shepard KG, Levin PS, Terris DJ. Balanced orbital decompression for Graves' ophthalmopathy[ J]. Laryngoscope, 1998, 108(11 Pt 1): 1648- 1653.

59、Wirtschafter JD, Chu AE. Lateral orbitotomy without removal of the lateral orbital rim[ J]. Arch Ophthalmol, 1988, 106(10): 1463-1468.

60、Sweeney AR , Shaftel SS, Jacobs SM, et al. Lateral wall orbital decompression: comparison of outcomes in rim sparing and temporary rim removal techniques[ J]. J Craniofac Surg, 2017, 28(2): 379-382.

61、Gong Y, Yin J, Tong B, et al. Original endoscopic orbital decompression of lateral wall through hairline approach for Graves' ophthalmopathy: an innovation of balanced orbital decompression[ J]. Ther Clin Risk Manag, 2018, 14: 607-616.

62、Graham SM, Brown CL, Carter KD, et al. Medial and lateral orbital wall surgery for balanced decompression in thyroid eye disease[ J]. Laryngoscope, 2003, 113(7): 1206-1209.

63、Baril C, Pouliot D, Molgat Y. Optic neuropathy in thyroid eye disease: results of the balanced decompression technique[ J]. Can J Ophthalmol, 2014, 49(2): 162-166.

64、Hernández-García E, San-Román JJ, González R , et al. Balanced (endoscopic medial and transcutaneous lateral) orbital decompression in Graves' orbitopathy[ J]. Acta Otolaryngol, 2017, 137(11): 1183- 1187.

65、Sellari-Franceschini S, Rocchi R, Marinò M, et al. Rehabilitative orbital decompression for Graves' orbitopathy: results of a randomized clinical trial[ J]. J Endocrinol Invest, 2018, 41(9): 1037-1042.

66、Choi SU, Kim KW, Lee JK. Surgical outcomes of balanced deep lateral and medial orbital wall decompression in Korean population: clinical and computed tomography-based analysis[ J]. Korean J Ophthalmol, 2016, 30(2): 85-91.

67、徐贺, 吴桐, 孙丰源, 等. 眼眶平衡减压术与经鼻内窥镜内下壁减压术治疗高眶压的疗效对比[ J]. 中华实验眼科杂志, 2020, 38(11): 967-972.
Xu H, Wu T, Sun FY, et al. Comparison of the effects of balanced orbital decompression and endoscopic transnasal inferomedial wall decompression with the high orbital pressure[ J]. Chin J Exp Ophthalmol, 2020, 38(11): 967-972.

68、Fichter N, Guthoff RF. Results after en bloc lateral wall decompression surgery with orbital fat resection in 111 patients with Graves' orbitopathy[ J]. Int J Endocrinol, 2015, 2015: 860849.

69、Wright ED, Dav idson J, Codere F, et al. Endoscopic orbital decompression with preservation of an inferomedial bony strut: minimization of postoperative diplopia[ J]. J Otolaryngol, 1999, 28(5): 252-256.

70、Bleier BS, Lefebvre DR , Freitag SK . Endoscopic orbital floor decompression with preservation of the inferomedial strut[ J]. Int Forum Allergy Rhinol, 2014, 4(1): 82-84.

71、Goldberg RA, Wu JC, Jesmanowicz A, et al. Eyelid anatomy revisited. Dynamic high-resolution magnetic resonance images of Whitnall’s ligament and upper eyelid structures with the use of a surface coil[ J]. Arch Ophthalmol, 1992, 110(11): 1598-1600.

72、Mainville NP, Jordan DR. Effect of orbital decompression on diplopia in thyroid-related orbitopathy[ J]. Ophthalmic Plast Reconstr Surg, 2014, 30(2): 137-140.

73、Nair AA, Ediriwickrema LS, Dolman PJ, et al. Predictive modeling of new-onset postoperative diplopia following orbital decompression for thyroid eye disease[ J]. Ophthalmic Plast Reconstr Surg, 2022, 38(6): 551-557.

74、R A,Goldberg,N,Shorr,M S,Cohen.The medical orbital strut in the prevention of postdecompression dystopia in dysthyroid ophthalmopathy.[ J].Ophthalmic plastic and reconstructive surgery, 1992, 8(1): 32-4.

75、Wright ED, Dav idson J, Codere F, et al. Endoscopic orbital decompression with preservation of an inferomedial bony strut: minimization of postoperative diplopia[ J]. J Otolaryngol, 1999, 28(5): 252-256.

76、Finn AP, Bleier B, Cestari DM, et al. A retrospective review of orbital decompression for thyroid orbitopathy with endoscopic preservation of the inferomedial orbital bone strut[ J]. Ophthalmic Plast Reconstr Surg, 2017, 33(5): 334-339.

77、Long JA, Baylis HI. Hypoglobus following orbital decompression for dysthyroid ophthalmopathy[ J]. Ophthalmic Plast Reconstr Surg, 1990, 6(3): 185-189.

78、Paridaens DA, Verhoeff K, Bouwens D, et al. Transconjunctival orbital decompression in Graves' ophthalmopathy: lateral wall approach ab interno[ J]. Br J Ophthalmol, 2000, 84(7): 775-781.

79、Bailey KL, Tower RN, Dailey RA. Customized, single-incision, three-wall orbital decompression[ J]. Ophthalmic Plast Reconstr Surg, 2005, 21(1): 1-9; discussion 9-10.

80、Naik VM, Naik MN, Goldberg RA, et al. Immunopathogenesis of thyroid eye disease: emerging paradigms[ J]. Surv Ophthalmol, 2010, 55(3): 215-226.

81、Gillespie EF, Smith TJ, Douglas RS. Thyroid eye disease: towards an evidence base for treatment in the 21st century[ J]. Curr Neurol Neurosci Rep, 2012, 12(3): 318-324.

82、Lal P, Thakar A, Tandon N. Endoscopic orbital decompression for Graves' orbitopathy[ J]. Indian J Endocrinol Metab, 2013, 17(2): 265- 270.

83、Oeverhaus M, Copei A , Mattheis S, et al. Influence of orbital morphology on proptosis reduction and ocular motility after decompression surgery in patients with Graves' orbitopathy[ J]. PLoS One, 2019, 14(6): e0218701.

84、Jimenez-Chobillon MA, Lopez-Oliver RD. Transnasal endoscopic approach in the treatment of Graves ophthalmopathy: the value of a medial periorbital strip[ J]. Eur Ann Otorhinolaryngol Head Neck Dis, 2010, 127(3): 97-103.

85、Metson R, Samaha M. Reduction of diplopia following endoscopic orbital decompression: the orbital sling technique[ J]. Laryngoscope, 2002, 112(10): 1753-1757.

86、Vaidya A, Kakizaki H, Takahashi Y. Changes in field of binocular single vision and ocular deviation angle after balanced orbital decompression in thyroid eye disease[ J]. Ophthalmic Plast Reconstr Surg, 2021, 37(2): 154-160.

87、郑嵩山, 柴昌. 改良眼眶减压术对甲状腺相关眼病术后眼位的保护作用[ J]. 中华实验眼科杂志, 2020, 38(11): 951-956.
Z heng SS, Chai C. Protect ive ef fect of a modi f ied orb ital decompression for postoperative eye position in thyroid-associated ophthalmopathy[ J]. Chin J Exp Ophthalmol, 2020, 38(11): 951-956.

88、Seiff SR, Tovilla JL, Carter SR, et al. Modiffed orbital decompression for dysthyroid orbitopathy[ J]. Ophthalmic Plast Reconstr Surg, 2000, 16(1): 62-66.

1、深圳市科技创新委员会课题基金(GJHZ20190821113605296)

其他期刊

眼科学报

主管：中华人民共和国教育部
主办：中山大学
承办：中山大学中山眼科中心
主编：林浩添

主管：中华人民共和国教育部
主办：中山大学

浏览
Eye Science

主管：中华人民共和国教育部
主办：中山大学
承办：中山大学中山眼科中心
主编：林浩添

主管：中华人民共和国教育部
主办：中山大学

浏览

一亿年进化出的晶状体有多重要？

发布于: 2022-12-01