Oeverhaus Michael, Fischer Maragrethe, Schlüter Anke, Esser Joachim, Eckstein Anja
Klinik für Augenheilkunde, Universitätsklinikum Essen.
Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Universitätsklinikum Essen.
Klin Monbl Augenheilkd. 2018 Oct;235(10):1105-1114. doi: 10.1055/a-0719-5354. Epub 2018 Oct 16.
Patients with Graves' orbitopathy (GO) often show severe esotropia after decompression surgery, especially in cases with severe enlargement of muscles before decompression. In severely afflicted patients, simple recessions of the medial rectus muscle are not sufficient. In these patients, tendon elongation with bovine pericardium (Tutopatch) is an alternative for simultaneous resection of the lateral rectus muscle. We retrospectively analysed our clinical data of patients who underwent corrective surgery of the medial rectus following three-wall decompression surgery.
Patients who underwent classical uni- or bilateral medial recession (MR, BMR; n = 87) or bilateral medial recessions combined with tendon elongation with a graft at one or both muscles (n = 60), were analysed for surgical success (≤ 10 esotropia, central 20° field of binocular single vision), dose effect (° per mm recession/elongation distance) and postoperative ductions. Clinical data directly after surgery and 3 and 12 months later were evaluated in a retrospective manner.
All patients showed lower dose effects compared to medial recessions without prior decompression: Unilateral recession 1.2 ± 0.4°/mm, bilateral 1.0 ± 0.3°/mm, unilateral tendon elongation with contralateral simple recession 0.92 ± 0.3°/mm and bilateral tendon elongation 0.87 ± 0.3°/mm. Because of a preoperatively overestimated dose effect, some patients showed undercorrections after surgery. Under consideration of the actual dose effect, surgical success could often be achieved in these severely afflicted GO patients: After simple recessions in 90% and after tendon elongations in 70% of patients.
In patients following three-wall decompression, higher dosages have to be used for medial recessions and recessions with tendon elongation than with patients without prior decompression. Simple recessions are therefore only to be recommended up to 15° esotropia. In more severe cases up to 25°, tendon elongation can be used.
格雷夫斯眼眶病（GO）患者在减压手术后常出现严重内斜视，尤其是在减压前肌肉严重肿大的情况下。在病情严重的患者中，单纯的内直肌后徙术并不足够。对于这些患者，使用牛心包进行肌腱延长术（Tutopatch）是同时切除外直肌的一种替代方法。我们回顾性分析了接受三壁减压手术后内直肌矫正手术患者的临床资料。
对接受经典单侧或双侧内直肌后徙术（MR，BMR；n = 87）或双侧内直肌后徙术联合一侧或双侧肌肉肌腱延长术（n = 60）的患者进行手术成功率（≤10 度内斜视，中央 20°双眼单视视野）、剂量效应（每毫米后徙/延长距离的度数）和术后眼球运动的分析。对术后即刻、3 个月和 12 个月的临床资料进行回顾性评估。
与未进行减压的内直肌后徙术相比，所有患者的剂量效应均较低：单侧后徙为 1.2±0.4°/mm，双侧为 1.0±0.3°/mm，单侧肌腱延长联合对侧单纯后徙为 0.92±0.3°/mm，双侧肌腱延长为 0.87±0.3°/mm。由于术前对剂量效应估计过高，一些患者术后出现矫正不足。考虑到实际剂量效应，这些病情严重的 GO 患者通常可以实现手术成功：单纯后徙术后成功率为 90%，肌腱延长术后成功率为 70%。
在接受三壁减压手术的患者中，与未进行过减压的患者相比，内直肌后徙术和肌腱延长术需要使用更高的剂量。因此，单纯后徙术仅推荐用于内斜视 15°以内的情况。在更严重的病例中，内斜视可达 25°，可使用肌腱延长术。
