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Director Tu Yunhai: Progress in diagnosis and treatment of thyroid-related ophthalmopathy with endoscopic orbital decompression

Posting time:2023-01-31 09:56:39

Director Tu Yunhai: Progress in diagnosis and treatment of thyroid-related ophthalmopathy with endoscopic orbital decompression

Editor's note Thyroid associated ophthalmopathy (TAO) is the most common orbital disease in adults, and its pathogenesis is currently unknown. Orbital decompression surgery is still an important treatment for TAO. With the development of technology, in recent years, endoscopic technology has become an effective and safe treatment method for orbital decompression surgery because of its direct vision, good lighting, no severe facial scars, and good visibility of key anatomical positions, leading orbital decompression. Surgery has entered a new era of minimally invasive surgery. The team of Professor Wu Wencan from the Ophthalmology Hospital Affiliated to Wenzhou Medical University has been committed to the endoscopic minimally invasive diagnosis and treatment of thyroid-related ophthalmopathy, and has now achieved full coverage of endoscopic multi-wall orbital decompression surgery, truly realizing the endoscopic minimally invasive TAO. diagnosis and treatment. At the 2022 Vision China International Forum on Innovation and Development of Vision Health, Director Yunhai Tu brought a glimpse of the progress of endoscopic orbital decompression in the treatment of thyroid-related ophthalmopathy. Perfect: endoscopic medial orbital wall decompression endoscopic transethmoidal approach can provide a direct access to the orbital apex, and can also deal with sinus drainage problems, and has become the first choice for internal wall decompression. In the correction of proptosis, conventional transnasal endoscopic bony decompression of the medial orbital wall has no advantage in the correction of proptosis. Based on these limitations, Director Wu proposed to use endoscopic medial wall decompression combined with suction rongeurs to extract fat inside and outside the muscle cone to decompress the thyroid-related ophthalmopathy, which reduced the exophthalmos by 8.2±1.8mm on average. . Image 1 from Wu W, Selva D, Bian Y, et al. Endoscopic medial orbital fat decompression for proptosis in type 1 graves orbitopathy. Am J Ophthalmol. 2015. 159(2): 277-84. Optic neuropathy in thyroid-related ophthalmopathy In the treatment of dysthyroid optic neuropathy (DON), the current mainstream view is that the pathogenesis of DON is orbital apex crowding, so adequate decompression of the orbital apex is the key to surgery. On the basis of combining the previous techniques and considering the purpose of adequate decompression, Director Wu and Director Tu Yunhai further removed the inner wall of the pterygopalatine fossa (including the orbital surface of the jawbone) and the anterior wall (the maxillary sinus) on the basis of decompression of the orbital wall through the ethmoid approach. posterior wall) and part of the infraorbital wall, and anterior optic nerve decompression (see Figure 2), 93% of the patients had improved visual acuity after surgery, and only 4.05% (3/74) of the patients had postoperative visual acuity decline. After improvement, there is no need for second decompression surgery, showing good surgical results. Therefore, adequate decompression of the orbital apex is the key to DON treatment. As for whether to implement anterior optic nerve decompression, there is a certain controversy, and it is recommended that qualified physicians implement it reasonably according to their personal abilities. Figure 2. The conventional inner wall decompression range is marked in yellow, and the expanded decompression range is shown in purple (from Tu Y, Xu M, Kim AD, Wang M, Pan Z, Wu W. Modified endoscopic trans-nasal orbital apex decompression in dysthyroid optic neuropathy. Eye Vis (Lond. 2021. 8(1): 19.) For transnasal and transorbital medial wall decompression, new and worse diplopia is usually 10%-55%, and even as high as 80%. report. Methods to reduce the incidence of diplopia include retaining the strut structure of the medial and inferior walls and retaining the orbital periosteal cuff. Although some serious complications have not been reported in the treatment of TAO under endoscopic transnasal orbital decompression surgery, the complications of transnasal surgery such as craniocerebral complications, internal carotid artery injury, extraocular muscle and even intraorbital optic nerve injury are common in the sinuses. Surgery has been reported, need to pay attention. Pioneering: Endoscopic lateral orbital wall decompression The traditional orbital lateral wall decompression removes the lateral orbital wall bone wall, resulting in mutual communication between the temporal fossa and the orbit, resulting in postoperative vibratory hallucinations, temporal fossa depression and other complications. Reports of its incidence vary. Director Wu and Director Tu used the "endoscopic keyhole technique" to perform deep decompression of the outer orbital wall through the lower palpebral conjunctival approach. Finally, a thin layer of bone wall is retained between the orbit and the temporal fossa, which fundamentally avoids the occurrence of the above-mentioned complications. Figure 3. The red tip is the greater sphenoid wing, (b is the preoperative coronal view, d is the postoperative horizontal view), and the white arrow is the greater sphenoid wing after bone grinding. (From Tu Y, Wu S, Pan Z, et al. Endoscopic Transconjunctival Deep Lateral Wall Decompression for Thyroid-associated Orbitopathy: A Minimally Invasive Alternative: Transconjunctival Endoscopic with Wall Decompression for TAO[J]. Am J Ophthalmol,2022,235: 71-79.) Combination: Endoscopic infraorbital wall decompression surgery Infraorbital wall decompression surgery is often used as an auxiliary decompression surgery method, and is performed in combination with intraorbital and lateral orbital surgery. During the process of decompression through the nasal orbital wall, combined intraorbital and infraorbital decompression that preserves the anterior strut structure can be performed. In addition, in practice, endoscopic decompression of the orbital outer wall through the lower palpebral conjunctival fornix approach can be performed at the same time, and endoscopic infraorbital wall decompression can be performed at the same time, which is helpful to improve the surgical effect of proptosis correction. The combined implementation of the above surgical methods achieves full coverage of endoscopic orbital wall decompression surgery, and truly realizes multi-wall endoscopic minimally invasive decompression surgery for TAO. Director Tu concluded that precision medicine is the development direction of future medical care. In the process of achieving minimally invasive development of endoscopic orbital decompression surgery, how to improve the accuracy of orbital decompression surgery has become a focus issue. Therefore, the formulation of a personalized surgical plan for orbital decompression surgery and the accurate prediction of the surgical effect will become the direction and goal of orbital decompression surgery in the future.

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