Endonasal technique for orbital decompression surgery in a patient with Graves’ exophthalmopathy

Abstract Female, 29, former smoker, diagnosed in September 2012 with Graves’ disease and rapid presentation of bilateral exophthalmos. In the ophthalmologic evaluation, it presented preserved motility, proptosis and upper fat sac in OA with retraction of PPSS and PPII and exophthalmetry in OD of 26 mm, and in OE of 24 mm. In May 2014, he performed the mapping of the retina that showed scars of chorioretinitis in both eyes and computerized campimetry, presenting a nasal step in OD, superior contraction, central-inferior depression. In June 2016, he underwent orbital decompression surgery of the medial and inferior bilateral walls by endoscopic approach using the Karl Storz nasal endoscope at 30 degrees of optics. The surgical approach of Graves’ ophthalmopathy should be used in the cicatricial phase except in cases with risk of loss of vision. Before performed by external access, orbital decompression can now be performed endoscopically, with minimal invasiveness and allows the removal of the inferior wall and Without external incisions. It is a safe procedure for the treatment of dysthyroidal orbitopathy, associated with lower morbidity, in which lesions are avoided in the nasolacrimal, nasofrontal, or infraorbital ducts and it is possible to reduce proptosis between 3 and 4 mm. The benefits of decompression are related to Improvement of visual acuity, besides the aesthetic result. The continuation of the surgical treatment will be performed by correction of palpebral retraction followed by blepharoplasty.

摘要 患者为29岁女性，有既往吸烟史，2012年9月确诊格雷夫斯病（Graves' disease），并快速进展为双侧突眼。眼科检查显示：眼球运动功能完好，存在眼球突出及眼眶上部脂肪垫，伴PPSS与PPII回缩；右眼（OD, Oculus Dexter）突眼计测量值为26mm，左眼（OE, Oculus Sinister）为24mm。2014年5月，患者行视网膜地形图检查，结果提示双眼脉络膜视网膜炎（chorioretinitis）瘢痕；同时行计算机视野检查（computerized campimetry），显示右眼存在鼻侧阶梯、上方视野收缩及中心下凹陷。2016年6月，患者接受内镜下双侧眼眶内下壁减压术，术中使用卡尔·史托斯（Karl Storz）30度鼻内镜。格雷夫斯眼病的手术治疗应于瘢痕期（cicatricial phase）实施，仅除外存在视力丧失风险的病例。相较于既往的外入路手术，当前内镜下眼眶减压术具备微创优势，可无需外部切口即可切除眶下壁，是治疗甲状腺相关性眼病（dysthyroidal orbitopathy）的安全术式，术后并发症发生率更低，可避免损伤鼻泪管（nasolacrimal duct）、鼻额管（nasofrontal duct）及眶下管（infraorbital duct），且能使眼球突出度降低3~4mm。该减压术的获益不仅可改善视力，还可获得理想的美学效果。后续手术治疗将依次行睑退缩（palpebral retraction）矫正术及眼睑成形术（blepharoplasty）。