發(fā)布時間：2018-06-04 07:44

  本文選題：外傷性視神經(jīng)病變 + 眶壁骨折　； 參考：《吉林大學》2011年碩士論文

【摘要】：由于生活方式的改變和CT等各類檢查手段的不斷進步,越來越多的眼科醫(yī)生能夠準確的認識并發(fā)現(xiàn)外傷性視神經(jīng)病變(Traumatic Optic Neuropathy, TON)的患者。在各類國內(nèi)外文獻中,外傷性視神經(jīng)病變患者的受傷途徑、致盲原因以及視力損傷程度、外傷到治療前時間、治療方法等影響因素方面的研究結(jié)論雖然有些共同認識,但是分歧較大。在對這類病人的研究中,其致盲原因以及視力損傷程度與可能伴發(fā)的不同類型的眶壁骨折的關(guān)系研究結(jié)果甚少,針對TON患者的相關(guān)治療手段以及治療的結(jié)果也同樣眾說紛紜。所以,在眼外傷病人較多、規(guī)模較大、能夠滿足術(shù)后隨訪要求的的眼科中心進行一個以眼科醫(yī)生為主體的系統(tǒng)性臨床研究是非常有價值的。 以眼科醫(yī)生為主體,以中國東北地區(qū)中心城市長春的一個眼科中心(吉林大學第二醫(yī)院眼科醫(yī)院)收治的外傷性視神經(jīng)病變的病人為研究對象,研究分析其基本臨床流行病學特征、視神經(jīng)管及眶壁骨折的CT影像學特點、合并眶壁骨折的TON臨床特征以及相關(guān)診斷及治療原則,歸納和總結(jié)分析TON患者是否合并眶壁骨折及骨折類型、受傷后視力、受傷到治療的時間、不同治療手段等影響外傷性視神經(jīng)病變患者視力預后的主要因素。 本研究為回顧性研究。納入研究范圍病例包括伴有或不伴有眶壁骨折的外傷性視神經(jīng)病變患者以及同期入院治療的眶壁骨折患者。對于外傷性視神經(jīng)病變患者,治療方法包括激素沖擊療法、視神經(jīng)管鼻內(nèi)窺鏡手術(shù)減壓法以及本課題組前期工作中的翼點入路視神經(jīng)管手術(shù)減壓法。 64例66眼外傷性視神經(jīng)病變患者中,27眼不伴發(fā)眶壁骨折,39眼伴發(fā)眶壁骨折。既同期眶壁骨折患者(579眼)中,6.7%伴發(fā)外傷性視神經(jīng)病變(39眼)。 ①TON是否伴發(fā)眶壁骨折對傷后視力及預后視力影響的研究結(jié)果：伴發(fā)眶壁骨折的TON患者39眼,20眼傷后無光感,17眼光感/手動/指數(shù),2眼視力0.05以上,其中8眼治療后視力有提高；無伴發(fā)眶壁骨折的TON患者27眼,10眼傷后無光感,11眼光感/手動/指數(shù),6眼視力0.05以上,其中10眼治療后視力有提高。應用列聯(lián)表卡方檢驗對傷后視力相關(guān)數(shù)據(jù)進行分析可得,|Z|=2.73,在拒絕域內(nèi),故伴發(fā)眶壁骨折患者傷后視力與不伴發(fā)眶壁骨折患者傷后視力差異有統(tǒng)計學意義。應用列聯(lián)表卡方檢驗對預后視力相關(guān)數(shù)據(jù)進行分析可得,|Z|=3.00,在拒絕域內(nèi),故伴發(fā)眶壁骨折患者預后視力與不伴發(fā)眶壁骨折患者預后視力差異有統(tǒng)計學意義。 ②伴發(fā)眶壁骨折類型對TON患者視力及預后視力影響的研究結(jié)果：對TON伴發(fā)外壁相關(guān)骨折21眼,治療后2眼視力有提高；TON伴發(fā)內(nèi)壁相關(guān)骨折19眼,治療后5眼視力有提高。上述病例中,內(nèi)壁骨折與外壁骨折皆有臨床意義的患者在兩組中重復計數(shù)。應用列聯(lián)表卡方檢驗對數(shù)據(jù)進行分析可得,|Z|=1.97,在拒絕域內(nèi),故外壁相關(guān)骨折患者預后視力與內(nèi)壁相關(guān)骨折患者預后視力差異有統(tǒng)計學意義。 ③受傷后到治療前時間的間隔對TON患者視力及預后視力影響的研究結(jié)果：TON患者傷后3天內(nèi)接受治療30眼,治療后13眼視力有提高；TON患者傷后3天后接受治療36眼,治療后6眼視力有提高。應用列聯(lián)表卡方檢驗對數(shù)據(jù)進行分析可得,|Z|=4.12,在拒絕域內(nèi),故傷后3天內(nèi)接受治療預后視力與傷后3天后接受治療預后視力差異有統(tǒng)計學意義。 ④受傷后殘存視力對TON患者視力預后影響的研究結(jié)果：傷后無光感30眼,治療后2眼視力有提高；傷后視力光感/手動/指數(shù)者27眼,治療后14眼視力有提高；傷后視力0.05及以上者9眼,治療后3眼視力有提高。應用列聯(lián)表卡方檢驗對數(shù)據(jù)進行分析可得,R=5.13,否定H0,故p1=p2=p3不成立,故傷后視力不同對患者預后視力差異有統(tǒng)計學意義。 ⑤治療方法的選擇對TON患者視力預后影響的研究結(jié)果：全身接受激素治療38眼,13眼視力有提高；經(jīng)鼻內(nèi)鏡行視神經(jīng)管減壓術(shù)13眼,3眼視力有提高；(前期工作)開顱視神經(jīng)管減壓術(shù)30眼,10眼視力有提高。應用列聯(lián)表卡方檢驗對數(shù)據(jù)進行分析可得,R=1.22,不否定H0,故p1=p2=p3成立,故三種治療手段對患者預后視力造成的差異無統(tǒng)計學意義。 我國東北地區(qū)外傷性視神經(jīng)病變患者中伴發(fā)眶壁骨折占同期眶壁骨折患者(579眼)的6.7%。 外傷性視神經(jīng)病變患者伴發(fā)的眶壁骨折情況(是否伴發(fā)骨折以及骨折類型)是影響患者傷后視力和預后視力的重要因素。伴發(fā)眶壁骨折患者傷后視力差于不伴發(fā)眶壁骨折患者；伴發(fā)眶壁骨折患者視力預后差于不伴發(fā)眶壁骨折患者；伴發(fā)外壁相關(guān)骨折患者視力預后差于伴發(fā)內(nèi)壁相關(guān)骨折患者；而本組中59%TON患者伴發(fā)眶壁骨折,也不失為TON患者普遍預后視力較差的原因之一 受傷到治療的時間長短明顯影響外傷性視神經(jīng)病變患者視力預后。傷后3天內(nèi)接受治療效果優(yōu)于傷后3天后接受治療患者； 傷后殘存視力是影響外傷性視神經(jīng)病變預后視力的又一重要因素。傷后無光感患者,無論采取何種治療手段,視力基本無提高可能,預后視力極差；傷后視力光感/手動/指數(shù)患者,視力提高人數(shù)比例較高；傷后視力0.05及以上者,視力提高人數(shù)比例高于無光感患者,低于光感/手動/指數(shù)患者； 對治療方法的評價表明,不同的治療手段對外傷性視神經(jīng)病變患者視力預后的影響不大。
[Abstract]:More and more ophthalmologists have been able to accurately recognize and discover patients with traumatic optic neuropathy (Traumatic Optic Neuropathy, TON) due to the change of lifestyle and the continuous progress of various methods such as CT. In all kinds of domestic and foreign literature, the way of traumatic optic neuropathy, the cause of blindness and the damage of visual acuity In the study of this type of patients, the cause of blindness and the degree of visual impairment with the different types of fracture of the orbital wall and the related treatment for TON patients are very small. The results of the means and treatment are also different. Therefore, it is of great value to carry out a systematic clinical study based on the ophthalmologist in the ophthalmology center with more ocular trauma patients and larger scale, which can meet the follow-up requirements after the operation.
Taking the ophthalmologist as the main body and taking the patients with traumatic optic neuropathy treated in one eye center (Second Hospital of Jilin University) in the central city of Northeast China (Jilin University second hospital), the basic clinical epidemiological characteristics, CT imaging features of optic canal and orbital wall fracture, and TON of orbital wall fracture were combined. The clinical features and the principles of related diagnosis and treatment are summarized and summarized to analyze whether TON patients merge with orbital wall fracture and fracture type, visual acuity after injury, time of injury to treatment, and the main factors that affect visual prognosis of patients with traumatic optic neuropathy.
This study included a retrospective study. The included cases included patients with traumatic optic neuropathy accompanied by or without orbital fracture and orbital wall fractures in the same period. For patients with traumatic optic neuropathy, the treatment methods included hormone shock therapy, optic canal nasal endoscopic decompression, and the subject group. Pterional approach for decompression and decompression of optic canal in previous work.
Of 64 cases of 66 eyes with traumatic optic neuropathy, 27 eyes did not have orbital wall fracture and 39 eyes were associated with orbital wall fracture. In the same period, 6.7% of the orbital wall fractures (579 eyes) were accompanied by traumatic optic neuropathy (39 eyes).
(1) the effect of TON with orbital wall fracture on visual acuity and visual acuity after injury: 39 eyes of TON patients with orbital wall fracture, 20 eyes without light sensation, 17 eye sense / manual / index, 2 eyesight more than 0.05, of which 8 eyes were improved after treatment; 27 eyes of TON patients without orbital wall fracture, 10 eyes without light sensation, 11 eye sense / The visual acuity of 6 eyes was above 0.05, and the visual acuity after 10 eyes was improved. The vision related data of the post injury was analyzed by using the combined table chi square test. |Z|=2.73, in the rejection domain, the visual acuity difference between the patients with orbital wall fracture and without orbital wall fracture was statistically significant. The prognosis of visual acuity related data can be analyzed. |Z|=3.00, in the rejection domain, the visual acuity of the patients with orbital wall fracture and the prognosis of the patients without orbital wall fracture is statistically significant.
(2) the results of the effect of the type of orbital wall fracture on visual acuity and prognosis of TON patients: 21 eyes with TON associated with external wall fracture and improved visual acuity in 2 eyes after treatment; 19 eyes with TON associated internal wall fracture and 5 eyes improved after treatment. In the above cases, the patients with internal and external wall fractures were clinically significant in the two group. The analysis of the data was obtained by using the square table card square test. |Z|=1.97, in the rejection domain, the prognosis of the prognosis of the patients with the external wall related fracture was statistically significant with the prognosis of the patients with the internal wall related fracture.
(3) the results of the effect of the interval between the injured and the pre treatment time on the visual acuity and the visual acuity of TON patients: 30 eyes were treated within 3 days after 3 days after injury and 13 eyes were improved after treatment. 36 eyes were treated in 36 eyes 3 days after injury and 6 eyes were improved after treatment. The data were analyzed by using the contingency table test, |Z|=4.1 2, in the rejection area, 3 days after injury, the prognosis of visual acuity was significantly different from that of 3 days after injury.
(4) the effect of visual acuity after injury on the visual prognosis of TON patients: no light sensation after injury in 30 eyes, 2 eyes improved after treatment, 27 eyes of visual acuity / manual / index after injury, 14 eyes improved after treatment, 9 eyes of 0.05 and more eyes after injury, and 3 eyes improved after treatment. Row analysis can be obtained, R=5.13, negate H0, so p1=p2=p3 is not established, so different visual acuity after injury has a statistically significant difference in the prognosis of patients.
The effect of the choice of treatment on the visual prognosis of TON patients: total body receiving hormone therapy in 38 eyes, 13 eyes improved visual acuity, 13 eyes of optic canal decompression through nasal endoscopy, 3 eyes improved visual acuity, 30 eyes of craniotomy optic canal decompression and improvement in 10 eyes. Analysis can be obtained, R=1.22, does not negate H0, so p1=p2=p3 was established, so the three treatment methods on the prognosis of patients with visual acuity difference is not statistically significant.
The orbital wall fractures in patients with traumatic optic neuropathy in Northeast China accounted for 6.7%. of the orbital wall fracture patients (579 eyes).
The cases of orbital wall fracture associated with traumatic optic neuropathy (or not with fracture and fracture type) are important factors affecting the visual acuity and prognosis of the patients after injury. The visual acuity of the patients with orbital wall fracture is worse than that of the orbital wall fracture, and the prognosis of the patients with orbital wall fracture is worse than that of the patients without orbital wall fracture. The visual prognosis of the patients with associated external wall fracture is less than that of the patients with internal wall related fractures, but in this group 59%TON patients with orbital wall fracture are also one of the causes of poor prognosis in the patients with TON.
The duration of the injury to the treatment was significantly affected by the visual prognosis of the patients with traumatic optic neuropathy. The treatment effect within 3 days after injury was better than that of the patients after the injury 3 days after the injury.
Visual acuity after injury is another important factor affecting the visual acuity of traumatic optic neuropathy. No light sensation after injury, no matter what treatment, visual acuity is not improved and the prognosis is very poor; the visual acuity / manual / index patient after injury is higher than that of the case; the visual acuity is 0.05 or more after injury. The proportion of high person was higher than that of non photoreceptor patients, lower than light perception / manual / index patients.
Evaluation of treatment methods showed that different treatments had little effect on visual prognosis of patients with traumatic optic neuropathy.
【學位授予單位】：吉林大學
【學位級別】：碩士
【學位授予年份】：2011
【分類號】：R774

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