【作者】 袁先道；

【导师】 李娜；

【作者基本信息】 青岛大学 ， 耳鼻咽喉科学， 2004， 硕士

【摘要】 目的：本课题通过开展鼻内镜下经鼻腔、筛蝶窦入路视神经减压术，探索治疗外伤性视神经病的最佳治疗方法与手术路径。通过对术前视力、受伤至手术的时间、CT有无视神经管骨折与疗效的关系等方面的分析，找寻影响手术疗效的相关因素，为临床确定手术指证、判断预后提供依据。 方法：外伤性视神经病37例37只眼，在外伤后1-30天内施行鼻内镜下经鼻腔、筛蝶窦入路视神经减压术。术中开放筛、蝶窦，在蝶窦外上壁或Onodi气房内找寻视神经隆凸，以金刚石磨钻磨开视神经管，暴露管段视神经，切开鞘膜，施行减压。所有病人术前和术后给予激素治疗，根据最终视力分析影响疗效的因素。 结果：37例患者中21例术后视力获得改善，有效率为56.76％。其中，术前无光感者28例术后视力改善13例(46.43％)，术前视力有光感及以上者9例最终视力改善8例(88.89％)，二者差别有显著意义(P=0.029)。伤后时间小于7天者23例最终视力改善16例(69.57％)，伤后时间7天及以上者14例最终视力改善6例(42.86％)，二者差别无显著意义(P=0.104)。VEP监测中，能引出P100波的患眼术后疗效好于无P100波者(P=0.005)。 结论：①对于外伤性视神经病患者，大剂量激素冲击治疗无效时，应积极采用视神经减压术。②减压术后，视力恢复与否并不取决于伤后时间，而与视神经的损伤程度关系更大。对伤后1周以上者，手术减压仍有较好疗效。③术前视力有无光感，其手术后疗效有明显差别。但并非无光感患者就没有手术价值。④鼻内镜下视神经减压术，损伤小、疗效确切且不遗留面部瘢痕，有推广应用价值。⑤术前VEP检测情况对预测预后有一定的帮助。VEP检测应作为诊断外伤性视神经病的重要参考指标。更多还原

【Abstract】 OBJECTIVES: The proper management of traumatic injures to the optic nerve is controversial. Recommendations for management of traumatic injuries to the optic nerve in the literature include expectant management, medical therapy, surgical treatment, and medical therapy combined with surgical decompression. Traditional surgical approaches to optic nerve decompression (OND) are a craniotomy approach, extranasal transethmoidal approach, transorbital approach, transantral approach, and intranasal microscopic approach. Recent advances in instrumentation and surgical techniques have made an endoscopic approach to OND possible. The goal of this study is to search for a better surgical method for treatment of traumatic optic neuropathy and to identify factors affecting improvement in patients treated with OND and the diagnostic value of VEP in the traumatic optic neuropathy . METHODS: Thirty-seven patients(37 eyes)with traumatic optic neuropathy were enrolled. Transnasal endoscopic sphenoethmoidal optic nerve decompression was performed within 30 days after injury. Each patient was alert and free of injury to the globe when evaluated before surgery. All the patients were given preoperative and postoperative steroids. 13 patients were checked by VEP examination before and after surgery. The analyses of variations of visual acuity in final stage and VEP were to be done to determine the factors affecting the outcome of visual acuity and the diagnostic value of VEP in the traumatic optic neuropathy .RESULT: The final visual acuity was improved in 21 patients (56. 76 %) . The final visual acuity improved in 13/28 patients with no perception of light and 8/9 patients with light perception or better. The effectiveness in patients with light perception or better was significantly higher than those with no light perception, (p=0.029). Improvements were no significantdifference between patients whose course after injury less than 7 days and those whose course after injury were 7 days and more. (P=0. 104). The patients with presence of P-100 wave in VEP had better improvements than those without it(P=0. 005).CONCLUSION: The endoscopic method offers many advantages over the traditional approaches. Decreased morbidity, preservation of olfaction, rapid recovery time, more acceptable cosmetic results with no external scars, no risk of injury to the developing teeth in children, and less operative stress in a patient who may have multisystem trauma are only some of the benefits associated with the endoscopic OND. The key factor in determining nerve recovery was associated with the severity of optic nerve trauma. No light perception at initial is an important risk factor in the outcome. There is no reason to give up treatment even if the time after injury is more than 7 days. With or without P-100 wave in VEP is an important factor associated with prognosis.更多还原