| Thyroid associated ophthalmopathy(Thyroid Associated Ophthalmopathy,TAO)is an autoimmune disease that has a potential threat to visual function,and it predisposes to adults.Clinical studies have shown that most TAO patients can show abnormal thyroid function,but people with normal thyroid function can also be observed.TAO is a common cause of exophthalmos.The degree of exophthalmos in TAO patients has a certain relationship with the nature and treatment of hyperthyroidism.Epidemiological results show that there are differences in susceptibility to hyperthyroid exophthalmos(for example,the prevalence of female patients is 4-5 times that of male patients),which is closely related to the HLA-DR histocompatibility gene locus and environment.The early symptoms of TAO patients are not obvious,and some patients may show rabbit eyes,simple eyeballs,etc.,which makes early diagnosis difficult.The occurrence and development of TAO is a multifactorial process.If effective interventions are not taken as soon as possible after diagnosis,it will cause aggravation of ocular surface symptoms and affect the prognosis of patients.According to the clinical course,Grave’s ophthalmopathy can be divided into early stage,development(inflammatory stage)stage and late stage,stable stage.The worsening and remission of inflammation in the orbit is an early feature,usually lasting 6 to 18 months.Glucocorticoids,orbital radiotherapy,plasma exchange,somatostatin analogs,and orbital decompression are commonly used treatment methods in TAO patients,and different treatment methods have their own advantages and disadvantages.Clinical studies have shown that for TAO patients with relatively mild symptoms,special treatment and intervention are not needed,and it is enough to actively improve the patient’s thyroid function and correct bad living habits.For severe cases,highdose hormone therapy(HHT)intervention is required.HTT can effectively inhibit the hyperplasia of connective tissue,and can also reduce capillary permeability.At the same time,the use of HTT can reduce the exudation of inflammatory factors and reduce immunosuppression and inflammatory cell infiltration,which helps to improve the patient’s visual acuity and ocular surface lesions.Stable orbital manifestations are usually ineffective against steroids and radiation therapy.Severe exophthalmos can lead to serious consequences such as exposed keratopathy.Impairment of asymmetrical extraocular muscle function can lead to progressive diplopia,and optic neuropathy caused by expansion of the extraocular muscles and compression of the optic nerve or its vascular system.Optic neuropathy can lead to gradual loss of vision,decreased color vision,visual field defects,etc.,and ultimately can cause thyroid insufficiency optic neuropathy(DON).Surgery for TAO patients will be performed at this stage,including strabismus repair,eyelid retraction surgery,and orbital decompression.TAO’s surgical methods include orbital decompression,which can be broadly defined as any surgical procedure that reduces intraorbital pressure and its effects by expanding the bony structure of the orbit and/or removing orbital fat.Orbital decompression surgery is suitable for compressive optic neuropathy or severe corneal exposure,and can also be used to improve the beauty of disfiguring exophthalmos.Orbital decompression involves the removal of the bony orbital wall and orbital periosteum to cause the swollen orbital contents to prolapse into the adjacent space.Orbital decompression is considered to be an effective treatment for DON,which can reduce orbital inflammation,reduce orbital pressure,improve vision and reduce ocular protrusion.In an emergency,optic nerve compression and angular injury can be treated with rapid orbital decompression,which not only saves the patient’s vision,but also improves the patient’s quality of life.The content of this study is divided into two parts.The first part is the statistical observation and description of clinical characteristics of the collected patients with thyroid-related ophthalmopathy,and discusses the effect of hormone shock in patients with thyroid-related ophthalmopathy;the second part is a retrospective collection of thyroid insufficiency For patients with optic neuropathy,the clinical characteristics of best-corrected vision and exophthalmos after orbital decompression were performed to explore the efficacy of orbital decompression for the treatment of severe thyroid insufficiency optic neuropathy.Part I:Effect of Hormone Impact on the Treatment of Thyroid-related Eye DiseasePurposeTo observe and discuss the effect of hormone shock in patients with thyroid-related ophthalmopathy and its influence on visual acuity and ocular surface changes.1.Information and methodology1.1 Clinical data1.1.1 SubjectsThe selected subjects in this study are all patients with thyroid-related ophthalmopathy diagnosed in the outpatient clinic of the Department of Ophthalmology,the First Affiliated Hospital of Guangxi Medical University from April 2018 to March 2020.A total of 68 patients with Thyroid Associated Ophthalmopathy(TAO)were selected as subjects.They were divided into control group(n=34 cases,47 eyes)and observation group(n=34 cases,51 eyes)by random number table.Inclusion criteria:(1)Meet the TAO diagnostic criteria,and finally diagnose according to the corresponding auxiliary examination ultrasound,CT scan or MRI;(2)According to the clinical activity score(CAS)standard revised by the European Graves Eye Disease Collaboration Group,the activity score is≥3 The diseases are all in the active stage;(3)It meets the indications of prednisone acetate tablets and hormone shock therapy,and the patients can tolerate it.Exclusion criteria:(1)People with psychiatric disorders,blood system diseases,or autoimmune diseases that affect tear film stability(including:Sjogren’s syndrome,rheumatoid arthritis,etc.);(2)Ocular allergies People with history,history of ocular trauma,abnormal corneal stem cells or ocular surface diseases caused by other reasons;(3)People who have abnormal cognitive function,have used anesthetics,sedatives.1.1.2 Testing InstrumentsMN-6100 A power detector(Hefei Innovation Co.,Ltd.),IMMULITE2000(DPC company),Millennium VG with Hawkeye dual-probe SPECT(American GE company),Hawkeye exophthalmoscope(Suzhou Medical Equipment General Factory).1.1.3 Research TechniqueA total of 68 patients with thyroid-related ophthalmopathy in our hospital were selected as the research objects,and they were divided into a control group(n=34 cases,47 eyes)and an observation group(n=34 cases,51 eyes)by a random number table.The control group was treated with prednisone acetate tablets orally,and the observation group was treated with hormonal shock therapy.Both groups completed 6-month medication intervention to evaluate the effects of patients after treatment,and compare the clinical efficacy,visual acuity,ocular surface changes,and life of the two groups.Quality and drug safety.And record the patient’s medical history characteristics(including gender,age,time of onset,visual acuity level before treatment,exophthalmos,eye cleft width,family history,smoking history,drug treatment,presence or absence of iodine 131 treatment,etc.)information.The statistical method of this study was processed by SPSS 18.0 software.The count data was χ2 test,which was represented by n(%),the measurement data was represented by t test,which was represented by(±S).The data at multiple time points was analyzed by variance analysis,with P<0.05 The difference is defined as statistically significant.2.Results(1)Comparison of eyeball protrusion and palpebral fissure width:There was no statistical significance in eyeball protrusion and palpebral fissure width before treatment in the two groups(P>0.05);observation group and control group 6 months after treatment for eyeball protrusion and palpebral fissure The widths were higher than before treatment;the eyeball protrusion and palpebral fissure width of the observation group were higher than those of the control group at 6 months after treatment(P<0.05),which was statistically significant.(2)CAS score comparison:The CAS scores of the two groups before treatment were not statistically significant(P>0.05);the observation group and the control group had lower CAS scores at 1,3,and 6 months after treatment;the observation group was treated The CAS scores were lower than those of the control group(P<0.05),which was statistically significant.(3)Comparison of visual acuity levels between the two groups:the visual acuity levels of the two groups before treatment were not statistically significant(P>0.05);the visual acuity levels of the observation group and the control group were higher than before treatment at 1,3,and 6 months after treatment(P<0.05);The visual acuity of the observation group was higher than that of the control group at 1,3 and 6 months after treatment(P<0.05),which was statistically significant.(4)Comparison of ocular surface changes between the two groups:the levels of ocular surface features before treatment in the two groups were not statistically significant(P>0.05);the levels of TMH,BUT,and SIt in the observation group and the control group were higher than those before treatment(P<0.05);R-scan and FS levels were lower than before treatment(P<0.05);TMH,BUT,and SIt levels in the observation group were higher than those in the control group at 6 months after treatment(P<0.05);R-scan and FS levels were higher Lower than the control(P<0.05).(5)Comparison of the quality of life between the two groups:The quality of life scores of the two groups were not statistically significant(P>0.05);the quality of life scores of the two groups at 6 months after treatment were lower than those before the treatment(P<0.05);the physiological scores,psychological scores,and psychological scores of the observation group were 6 months after treatment.The scores of independence,environment and social relations were all higher than those of the control group(P<0.05),which was statistically significant.(6)Comparison of drug safety:The incidence of infection,gastrointestinal discomfort,abnormal blood pressure,abnormal liver and kidney function,and dizziness and sleepiness in the observation group and the control group during treatment were not statistically significant(P>0.05).3.ConclusionHormone shock therapy in patients with active thyroid-related ophthalmopathy can achieve high short-term curative effect,can improve the visual acuity of patients,improve the ocular surface environment,improve the quality of life of patients after treatment,and does not increase the incidence of adverse reactions.It is worthy of popularization and application.Part Ⅱ:Study on the Efficacy Evaluation of Orbital Decompression on TAOPurposeTo investigate the efficacy of orbital decompression on severe thyroidrelated eye diseases.1.Clinical Data1.1 Study ObjectsThe subjects selected for this study were all patients who underwent orbital decompression for treatment of Graves ophthalmopathy in the First Affiliated Hospital of Guangxi Medical University from January 2012 to July 2019.A total of 32 patients with thyroid ophthalmopathy(TED)were selected as the research objects.2 patients were lost to follow-up and 30 effective cases(41 eyes)were excluded,including 13 males and 17 females.Analyze the changes of best corrected visual acuity and exophthalmos and their correlation with clinical parameters.Inclusion criteria:All TED patients are Chinese citizens;they are≥18 years old;their thyroid function is basically stable;they are clinically diagnosed as patients with thyroid-related ophthalmopathy in grade Ⅴ-Ⅵ.Exclusion criteria:The postoperative follow-up was less than 28 days;suffering from sinusitis;combined with systemic diseases that affect surgery patients:patients with severe heart insufficiency,liver insufficiency,renal failure,uncontrolled hypertension,diabetes,etc.1.2 Research methodsThirty-two patients who were diagnosed with thyroid ophthalmopathy and underwent periorbital decompression in our hospital were selected as the research objects,and the postoperative best corrected visual acuity and changes in eyeball protrusion and their correlation with clinical parameters were analyzed.Each subject recorded the following data before treatment:1)Basic information and medical history,including age,gender,clinical activity score(CAS),duration of thyroid disease,previous treatment of thyroid disease,family history,ophthalmology history and smoking habits Analyze and other clinical parameters;2)Preoperative and postoperative best corrected visual acuity(BCVAs),intraocular pressure(IOP),orbital pressure,anterior slit lamp examination,pupil examination,fundus examination,eyelid swelling,eyelid retraction,lagophthalmia,Conjunctival hyperemia,eyeball alignment and movement.The Hertel exophthalmos method was used to evaluate exophthalmos,optic disc morphology,and disease severity.1.3 Statistical methodsSPSS 17.0 Windows(SPSS,Chicago,IL)software was used for statistical analysis.Preoperative and postoperative exophthalmos measurements,preoperative and postoperative BCVAs were compared by t-test or repeated measures analysis of variance.P<0.05 was considered statistically significant.The relationship between age,eyeball protrusion,optic disc morphology,corneal disease,clinical activity score,preoperative and postoperative best corrected visual acuity was evaluated by chi-square test or exact probability method.P<0.05 was considered to be statistically significant.2.ResultsDemographic characteristics:A total of 32 patients were included in the study.Two of them were lost to follow-up.Finally,30 patients(41 eyes)were included,including 13 males and 17 females.Clinical characteristics of patients:Eight out of 30 patients had symptoms of diplopia.18 cases were treated with steroids after orbital decompression,and 6 cases were treated with steroids before orbital decompression.5 patients received 1131 treatments,and 3 patients had a history of hypothyroidism.Postoperative efficacy:The preoperative BCVAs ranged from 0.00125 to0.1.The intraocular pressure range is 11-51mmHg,and the median is 21mmHg.Among 41 eyes,7 eyes had optic disc edema,8 eyes had slightly pale optic discs,and 29 eyes had normal optic discs.The median measurement of preoperative exophthalmos was 21mm(14-32 mm).The CAS ranged from 0 to 7,with a median of 2.41 eyes,4 eyes had corneal epithelial punctate defects,0 eyes had keratitis,5 eyes had corneal ulcers,and 32 eyes were normal.The postoperative BCVAs ranged from 1.6 to-0.2.BCVAs improved in 33 eyes,decreased in 3 eyes,and remained unchanged in 5 eyes.The median postoperative eyeball protrusion was 18(13-30),the degree of eyeball protrusion decreased by 2.95mm(±1.79 mm),the BCVAs after orbital decompression was significantly improved(P=0.039),and the degree of eyeball protrusion decreased significantly(P<0.001).Correlation between clinical parameters:Postoperative better BCVAs and preoperative better BCVAs(F=20.737,p<0.001,)and preoperative and postoperative comparison of eyelid retraction,incomplete eyelid closure,eye movement,conjunctival hyperemia and edema,optic disc and corneal morphology,Significant correlation,p<0.05,the differences are statistically significant,but there is no significant correlation with age,eyeball protrusion and CAS.3.ConclusionOrbital decompression is the most effective and safe operation for DON.It aims to reduce the increase in orbital pressure and eye apoptosis,and to treat exposure keratitis and thyroid dysfunction optic neuropathy.In the process of orbital decompression,1 to 3 bone orbital walls are removed,usually combined with orbital fat removal,so that the orbital soft tissue enters the super sinus,which can protect the remaining visual function of DON patients.The visual acuity before operation is better,and those with normal optic disc have better visual acuity after operation.The appropriate time for orbital decompression should be determined based on clinical parameters such as visual acuity and the degree of congestion at the orbital apex.Keep the indications for orbital decompression,prevent and treat complications,and achieve better surgical results. |
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