Tremolada C, Tremolada M A
Oculoplastic Surgery Service, Clinica Villa Letizia, Milan, Italy.
Plast Reconstr Surg. 1997 Jul;100(1):40-8; discussion 49-50. doi: 10.1097/00006534-199707000-00007.
Graves' ophthalmopathy may range from mild eyelid retraction to a devastating process that involves the entire orbit and culminates in gross ocular congestion, massive proptosis, and even blindness. Whether the ophthalmopathy is mild or severe, patients are managed on an individual basis according to the predominant clinical findings, which may include congestion, myopathy, lid retraction, proptosis, and optic neuropathy. The process usually becomes quiescent after 6 months to 3 years; however, the changes caused by fibrosis (lid retraction and ocular muscle enlargement) are permanent. The cornerstone of surgical treatment for severe cases is bony orbital decompression; however, in our experience, mild to moderate Graves' ophthalmopathy is better treated by combining eyelid surgery and orbital lipectomy. Our approach consists of a conservative orbital lipectomy, the lengthening of the levator-Müller complex by means of marginal myotomies, and a limited lateral tarsal apposition. These three different surgical steps, which have been described previously as isolated procedures, are undertaken on both eyes at the same time and modulated according to the deformity of the patient. The operation can be performed under local anesthesia with sedation, thus allowing intraoperative monitoring of the correction; the patient can be discharged after a few hours. The results in 32 operated eyes of 16 patients have been a marked aesthetic and functional improvement, with no complications after 6 to 18 months of follow-up. The relative simplicity and very low morbidity of this procedure, as well as its reliability, make it ideal in patients with mild to moderate aesthetic and functional impairment who are looking for a substantial improvement but are unwilling to undergo a relatively major procedure such as a transosseous decompression, which, in our opinion, is the operation of choice only when the patient presents with optic neuropathy or major proptosis.
格雷夫斯眼病的严重程度差异很大，从轻微的眼睑退缩到累及整个眼眶的破坏性病变，最终可导致严重的眼部充血、眼球明显突出甚至失明。无论眼病是轻度还是重度，均需根据主要临床症状进行个体化治疗，这些症状可能包括充血、肌病、眼睑退缩、眼球突出和视神经病变。该病程通常在6个月至3年之后趋于静止；然而，由纤维化引起的改变（眼睑退缩和眼肌增大）是永久性的。严重病例手术治疗的关键是眼眶骨减压；然而，根据我们的经验，轻至中度格雷夫斯眼病采用眼睑手术联合眼眶脂肪切除术治疗效果更佳。我们的手术方法包括保守性眼眶脂肪切除术、通过边缘肌切开术延长提上睑肌-米勒复合体，以及有限的外侧睑板贴合术。这三个不同的手术步骤，以前曾被描述为单独的手术，同时在双眼进行，并根据患者的畸形情况进行调整。手术可在局部麻醉加镇静的情况下进行，从而便于术中监测矫正情况；患者术后数小时即可出院。16例患者32只手术眼的结果显示，术后6至18个月随访，外观和功能均有显著改善，且无并发症发生。该手术相对简单，发病率极低，且可靠性高，对于轻至中度美学和功能受损、希望有显著改善但又不愿接受如经骨减压等相对大型手术的患者来说是理想选择。在我们看来，经骨减压仅在患者出现视神经病变或严重眼球突出时才是首选手术。
