目的：探讨直肌松解后退术联合眶脂肪切除对甲状腺相关性眼病限制性斜视的临床治疗效果。

方法：回顾分析2018-03/2019-06在我科住院的甲状腺相关性眼病限制性斜视病例27例34眼。所有患者均在全身麻醉下行直肌松解后退联合眶脂肪切除术。眶脂肪切除范围根据眼突的程度选择鼻下、颞下、鼻上或颞上等不同象限。25眼行下直肌后退术，5眼行内直肌后退术，4眼行上直肌后退术。术中根据眼球突出程度分别选择切除鼻下、颞下、鼻上或颞上等不同象限肌锥内、外脂肪，根据术前斜视度以及眼外直肌挛缩程度设计直肌手术的后退量，术中估计则依靠被动转动试验抗力的大小。术中切除脂肪量根据术前眼球突度，按切除约1mL脂肪眼球突度后退1mm设计。术后随访时间为每周1次，1mo后每月1次，3mo后不定期随访，所纳入手术患者随访时间在6mo以上。

结果：术中切除脂肪量2.1～3.4(平均2.6)mL。术后1mo视力为0～0.2(平均0.11±0.16)，术后6mo视力为0～0.3(平均0.12±0.17)，术前术后视力无差异(P>0.05)。术后1mo眼球突出度为13～16(平均14.4±0.8)mm，术后矫正眼球突出度2～4(平均2.4)mm(q=10.737，P<0.01)。术后6mo眼球突出度为13～15.5(平均14.5±0.6)mm，与术后1mo无差异(q=0.624，P=0.173)。术后1mo斜视度为2^△～10^△(平均6.7^△±2.3^△)，均为欠矫(q=18.068，P<0.01)，术前所有患者第一眼位均有复视，术后1mo第一眼位复视消失，6例患者下转15°眼位残留复视症状。所有患者的代偿头位均得到明显改善。术后6mo患者斜视度(欠矫)0^△～7^△(平均3.4^△±1.2^△)，与术后1mo有差异(q=5.385，P=0.015)。术后1mo眼压17.12±1.89mmHg，与术前眼压有差异(q=4.258，P=0.018)。术后6mo眼压17.53±1.67mmHg，与术后1mo无差异(q=0.729，P=0.154)。

结论：眶脂肪切除可改善眼突，并未对限制性斜视的手术设计及效果有明显影响，直肌松解后退术联合眶脂肪切除术治疗甲状腺相关性眼病限制性斜视合并突眼是一种可控的手术方案。

METHODS: From March 2018 to June 2019, 27 cases of restrictive strabismus with thyroid associated ophthalmopathy were retrospectively analyzed, 34 eyes in total. Under general anesthesia, all patients underwent rectus muscle release and orbital fat resection. The range of orbital fat resection was selected according to the degree of the ophthalmologic process in the subnasal, subtemporal, superior nasal, or superior temporal quadrants.Inferior rectus recession was performed in 25 eyes, medial rectus recession in 5 eyes and superior rectus recession in 4 eyes. According to the degree of exophthalmos, he internal and external fat of inferior nasal, infratemporal, Supranasal or supratemporal quadrant muscles were excised respectively during the operation. According to the preoperative strabismus degree and the degree of contraction of external rectus muscle, the recession amount of rectus operation was designed,and the strength of passive rotation test was estimated intraoperatively. The amount of fat removed during the operation was designed according to the degree of protrusion before operation, and it was designed to remove about 1mL fat and retract the eyeball by 1mm.The postoperative follow-up time was once a week, once a month after 1mo, and irregular follow-up after 3mo. All patients were followed up for more than 6mo.

RESULTS: The amount of fat removed was 2.1-3.4mL, with an average of 2.6mL.The visual(LogMAR)acuity was 0-0.2 in the 1mo after operation, with an average of 0.11±0.16. The visual acuity was 0-0.3 in the 6mo after operation, with an average of 0.12±0.17.There was no significant difference in visual acuity before and after operation(P>0.05). The degree of eyeball protrusion was 13-16mm, with an average of 14.4±0.8mm, and the degree of corrected eyeball protrusion was 2-4mm, with an average of 2.4mm(q=10.737, P<0.01). The degree of eyeball protrusion at 6mo after surgery was 13-15.5mm, with an average of 14.5±0.6mm, showing no significant difference from 1mo after surgery(q=0.624, P=0.173). 1mo after surgery, the strabismus was 2^△-10^△, with an average of 6.7^△±2.3^△, all of which were under correction(q=18.068, P<0.01). Before surgery, all the patients had diplopia at the first sight, and the first diplopia disappeared one month after surgery. All patients showed significant improvement in compensatory head position. The strabismus(undercorrection)of the patients at 6mo after surgery was 0^△-7^△, with an average of 3.4^△±1.2^△, and the difference was statistically significant compared with 1mo after surgery(q=5.385, P=0.015). The patient had no diplopia at the first and lower transitory position. The mean intraocular pressure after surgery(17.12±1.89mmHg)was lower than that before surgery, and the difference between preoperative and postoperative intraocular pressure was statistically significant(q=4.258, P=0.018).The mean intraocular pressure at 6mo after surgery was 17.53±1.67mmHg, with no significant difference from 1mo after surgery(q=0.729, P=0.154).

CONCLUSION: Orbital fat resection can improve the protrusion of the eyeball, but has no significant influence on the surgical design and effect of restrictive strabismus. It is a kind of controllable operation scheme to treat the limited strabismus with exophthalmos of thyroid associated ophthalmopathy with rectus muscle release and recession combined with orbital fat resection.