眼眶病眼眶肿瘤七制讲课

©ContinuingMedicalImplementation…...bridgingthecaregap眼眶病眼眶肿瘤©ContinuingMedicalImplementation…...bridgingthecaregap*眼眶的应用解剖©ContinuingMedicalImplementation…...bridgingthecaregap*眼眶概观 为四边锥体形骨性深腔 开口向前、向外，尖向后、向内 由额骨、筛骨、蝶骨、腭骨、泪骨、上颌骨和颧骨7块骨构成 成人眶深40-50mm©ContinuingMedicalImplementation…...bridgingthecaregap*眼眶整体观©ContinuingMedicalImplementation…...bridgingthecaregap*©ContinuingMedicalImplementation…...bridgingthecaregap*眶外壁 三角形，与正中平面呈45° 蝶骨大翼、颧骨眶突组成，最厚©ContinuingMedicalImplementation…...bridgingthecaregap*眶内壁 长方形 由上颌骨额突、泪骨、筛骨纸板、蝶骨体构成 前部为泪囊窝，由上颌骨额突及泪骨构成 筛骨纸板最薄，厚度仅为0.2-0.4mm，易骨折©ContinuingMedicalImplementation…...bridgingthecaregap*眶下壁（底壁） 大致呈三角形 由上颌骨眶面、颧骨眶突和腭骨眶突构成©ContinuingMedicalImplementation…...bridgingthecaregap*眶顶壁 呈三角形 由额骨的眶板及蝶骨小翼构成 泪腺窝：眶顶前外方凹陷，容纳泪腺 滑车小凹：邻近突出部为滑车棘©ContinuingMedicalImplementation…...bridgingthecaregap*眼眶通道 眶上裂：大小翼间，外段硬脑膜封闭，内段有动眼、滑车、外展及眼神经以及眼静脉通过 眶下裂：眶外、下壁之间，与翼腭窝、颞下窝相通，有上颌、颧、蝶腭神经节的眶支及眼下静脉吻合支经过 视神经管：小翼的二个根形成，沟通眶尖至颅中窝，正中面成36°。内侧是蝶窦，有时有后筛窦，通过视神经及其鞘，眼动脉©ContinuingMedicalImplementation…...bridgingthecaregap*眼外肌 眼外肌为横纹肌，均起于Zinn氏环，止于巩膜 上直肌：动眼神经上支支配 下直肌：动眼神经下支支配 内直肌：动眼神经下支支配 外直肌：外展神经支配 上斜肌：肌腱穿过滑车，滑车是U行纤维软骨，位于眶缘后约4mm处，滑车神经支配。成人滑车常见骨化 下斜肌：行于下直肌和眶底壁之间，动眼神经下支支配 提上睑肌：上直肌与眶顶壁间前行，腱膜呈扇形附着于眼睑，动眼神经上支支配©ContinuingMedicalImplementation…...bridgingthecaregap*眼眶肌肉©ContinuingMedicalImplementation…...bridgingthecaregap*视路 视神经：全长5cm，直径3mm，分颅内、管内、眶内、球内段。有髓鞘，无Schwann细胞，神经鞘膜由软脑膜、蛛网膜、硬脑膜构成，存在硬膜下隙、蛛网膜下隙，与颅内沟通 视交叉：横径10-20mm，前后径4-13mm，厚2-5mm，5%沟内，12%垂体窝前上，79%窝上，4%窝后上方。视交叉位于蝶鞍上方5-10mm 视束 外侧膝状体 视皮质 视辐射©ContinuingMedicalImplementation…...bridgingthecaregap*视神经©ContinuingMedicalImplementation…...bridgingthecaregap*泪器解剖 泪器：包括泪腺，泪点、泪小管、泪囊及鼻泪管 泪腺：位于泪腺窝，分眶部和睑部，眶部占2/3 泪囊：泪囊窝内，上为盲端，下到鼻泪管 鼻泪管：由上颌骨泪沟、泪骨泪沟和下鼻甲泪突所构成，沟通眼眶与下鼻道。©ContinuingMedicalImplementation…...bridgingthecaregap*泪道系统©ContinuingMedicalImplementation…...bridgingthecaregap*眶骨膜 衬眶骨眶面，与眶骨粘连疏松，骨缝处粘连牢固 于眶缘处增厚形成缘弓并与面部骨膜连续 经眶上裂、视神经管硬脑膜相连©ContinuingMedicalImplementation…...bridgingthecaregap*眶内间隙 骨膜下间隙：潜在性腔隙，常见骨瘤、巨细胞瘤、鼻源性肿瘤的眶内侵犯、脓肿或血肿等 肌锥外间隙（周边间隙）：肌锥与骨膜之间 肌锥内间隙：肌锥内，有脂肪及神经血管组织©ContinuingMedicalImplementation…...bridgingthecaregap*眼眶间隙©ContinuingMedicalImplementation…...bridgingthecaregap*内壁筛窦下壁上颌窦内壁筛窦内上方额窦上壁前颅窝眶壁与颅腔及鼻窦关系密切 视神经孔 眶上裂 眶下裂©ContinuingMedicalImplementation…...bridgingthecaregap*眼眶病的诊断©ContinuingMedicalImplementation…...bridgingthecaregap*疼痛炎症、感染、出血、恶性肿瘤进展急急性炎症、出血、恶性肿瘤缓良性肿瘤、慢性炎症既往史外伤史全身病家族史病史©ContinuingMedicalImplementation…...bridgingthecaregap*影像学诊断©ContinuingMedicalImplementation…...bridgingthecaregap*超声检查声阻差声的反射内回声病变区声衰减性质©ContinuingMedicalImplementation…...bridgingthecaregap*计算机体层摄影 能源为X线的二维图像 密度成像眼眶病的揭示率高 扫描平面水平、冠状和矢状 增强扫描血供情况©ContinuingMedicalImplementation…...bridgingthecaregap*正常眼眶CT图像（水平位）外直肌内直肌视神经©ContinuingMedicalImplementation…...bridgingthecaregap*正常眼眶CT图像（冠状位）外直肌上斜肌下直肌上直肌提上睑肌眼上静脉外直肌视神经©ContinuingMedicalImplementation…...bridgingthecaregap*磁共振成像 氢核密度氢核多信号强 多方位成像 视神经等软组织分辨力高 骨结构、钙化和异物等缺乏信号©ContinuingMedicalImplementation…...bridgingthecaregap*正常眼眶MRI图像（水平位）内直肌眼上静脉视神经外直肌泪腺©ContinuingMedicalImplementation…...bridgingthecaregap*正常眼眶MRI图像（冠状位）外直肌视神经内直肌下直肌上斜肌上直肌眼上静脉©ContinuingMedicalImplementation…...bridgingthecaregap*T1WIT2WI©ContinuingMedicalImplementation…...bridgingthecaregap*眶蜂窝织炎©ContinuingMedicalImplementation…...bridgingthecaregap*病因邻近感染扩散鼻窦、鼻腔、牙齿面部疖肿、睑腺炎眼眶自身病变眶骨膜炎眶外伤伴异物存留眼眶手术后感染©ContinuingMedicalImplementation…...bridgingthecaregap*临床表现 隔前蜂窝织炎、隔后蜂窝织炎 眼睑红肿，眼球突出（高度），眼球运动障碍，眼球转动痛，视乳头水肿、充血，晚期视乳头萎缩 眼眶脓肿、眶尖综合征、海绵窦血栓、脑膜炎、脑脓肿、败血症©ContinuingMedicalImplementation…...bridgingthecaregap*影像学诊断超声探查 急性期球后脂肪垫扩大 化脓期眼球后呈弧形暗区 脓肿期低回声区灶©ContinuingMedicalImplementation…...bridgingthecaregap*CT成像弥漫性高密度影，不规则，界不清眼环增厚眼外肌被遮蔽或显示肿大视神经增粗付鼻窦密度增高粘膜肥厚液平面MRI成像T1WI中信号T2WI高信号©ContinuingMedicalImplementation…...bridgingthecaregap©ContinuingMedicalImplementation…...bridgingthecaregap©ContinuingMedicalImplementation…...bridgingthecaregap*治疗 抗感染早期足量广谱 糖皮质激素适当 局部处理抗感染滴眼液涂眼膏 脓肿切开引流术 并发症处理败血症©ContinuingMedicalImplementation…...bridgingthecaregap*炎性假瘤©ContinuingMedicalImplementation…...bridgingthecaregap*病因免疫反应性疾病病因不明病理变化特发性瘤样炎症多形性炎症细胞＋纤维血管组织组织学分型淋巴细胞浸润型纤维增生型混合型©ContinuingMedicalImplementation…...bridgingthecaregap*临床表现 急性起病 眼眶痛、眼球运动障碍、复视和眼球突出 眼睑和结膜肿胀、充血 眶缘肿物结节状多发可推动轻压痛 晚期视神经萎缩上睑下垂眼球固定©ContinuingMedicalImplementation…...bridgingthecaregap*©ContinuingMedicalImplementation…...bridgingthecaregap*影像学诊断受累部位多眶脂肪泪腺眼外肌视神经特点多样化眶脂肪内高密度影眼环增厚眶腔扩大视神经增粗泪腺肿大眼外肌肥大©ContinuingMedicalImplementation…...bridgingthecaregap*©ContinuingMedicalImplementation…...bridgingthecaregap*治疗 糖皮质激素炎性细胞浸润型敏感 局部应用糖皮质激素 免疫抑制剂环磷酰胺 小剂量放疗淋巴细胞浸润型敏感©ContinuingMedicalImplementation…...bridgingthecaregap*甲状腺相关性眼病©ContinuingMedicalImplementation…...bridgingthecaregap*细胞介导的自身免疫性疾病病理变化眼外肌水肿、淋巴细胞浸润、肌肉变性坏死及纤维化球后脂肪等软组织炎性改变临床分型功能亢进型功能低下型功能正常型病因©ContinuingMedicalImplementation…...bridgingthecaregap*临床表现 眼睑退缩 眼睑滞后 眼球突出 复视眼球运动障碍 球结膜水肿 暴露性角膜炎©ContinuingMedicalImplementation…...bridgingthecaregap* 眼部保护性治疗滴用眼药涂眼膏 药物抗炎治疗糖皮质激素免疫抑制剂 放射治疗 手术治疗眼睑退缩矫正术眼外肌延长或缩短术眼眶减压术治疗©ContinuingMedicalImplementation…...bridgingthecaregap*皮样囊肿和表皮样囊肿©ContinuingMedicalImplementation…...bridgingthecaregap*迷芽瘤皮样囊肿囊壁角化的复层鳞状上皮毛囊皮脂腺囊内容脱落上皮毛发皮脂腺分泌物表皮样囊肿囊壁表皮囊内容角蛋白病因©ContinuingMedicalImplementation…...bridgingthecaregap* 好发部位外上眶缘内上或内下眶缘 眶缘肿物圆形表面光滑无压痛 眼球受压迫屈光不正 侵蚀眶缘 眶缘瘘管 渐进性眼球突出并向下移位临床表现©ContinuingMedicalImplementation…...bridgingthecaregap*©ContinuingMedicalImplementation…...bridgingthecaregap*超声探查 呈圆形、椭圆形 边界清楚 可压缩性 回声有区别 声衰减不明显©ContinuingMedicalImplementation…...bridgingthecaregap*©ContinuingMedicalImplementation…...bridgingthecaregap*CT扫描 颞上方圆形或类圆形占位 边界清楚高密度环 肿瘤内部不均质环形增强 指压痕或呈哑铃状MRI扫描 囊壁均呈现低信号 囊内容高信号或斑驳状©ContinuingMedicalImplementation…...bridgingthecaregap*手术治疗 手术完全切除囊壁去除干净 位于骨膜下者囊壁刮除石炭酸腐蚀治疗©ContinuingMedicalImplementation…...bridgingthecaregap*海绵状血管瘤©ContinuingMedicalImplementation…...bridgingthecaregap*错构瘤病理类圆形或肾形紫红色有完整包膜由大小不等的血管窦构成窦壁为平滑肌间质为结缔组织隔病因©ContinuingMedicalImplementation…...bridgingthecaregap* 无痛性、慢性进行性眼球突出 视力不受影响 眶前部肿瘤局部隆起紫蓝色 眶深部肿瘤压迫眼球有弹性阻力 眶尖部肿瘤视神经萎缩 眼球运动障碍、复视 眼底视网膜压迫条纹临床表现©ContinuingMedicalImplementation…...bridgingthecaregap*©ContinuingMedicalImplementation…...bridgingthecaregap*超声探查 A超内反射中高波峰，Ossani角<45o B超圆或椭圆形界清有肿瘤晕圆滑内回声多而强分布均匀中等度声衰减压迫变形©ContinuingMedicalImplementation…...bridgingthecaregap*©ContinuingMedicalImplementation…...bridgingthecaregap*CT扫描 肿瘤呈圆、椭圆或梨形 界清圆滑 内密度均质 眶尖部三角型透明区MRI扫描 T1WI中等信号 T2WI高信号©ContinuingMedicalImplementation…...bridgingthecaregap*©ContinuingMedicalImplementation…...bridgingthecaregap* 体积小、发展慢、视力好、眼球突出不明显可观察 影响视力或有症状可手术治疗治疗©ContinuingMedicalImplementation…...bridgingthecaregap*脑膜瘤©ContinuingMedicalImplementation…...bridgingthecaregap* 多发成年女性 四联征视力丧失一侧性眼球突出慢性视乳头水肿性萎缩视睫状静脉 疼痛及眼睑水肿 眼球运动障碍临床表现©ContinuingMedicalImplementation…...bridgingthecaregap*CT扫描 视神经增粗呈管状，梭形或锥形内密度均质异常钙化 眶骨增生肥厚 眶骨吸收和破坏 车轨样征象©ContinuingMedicalImplementation…...bridgingthecaregap*MRI扫描 视神经增粗T1WI中低信号T2WI高信号 车轨样征象 轮廓显示佳 视神经管内、颅内蔓延显示良好 脂肪抑制＋增强扫描©ContinuingMedicalImplementation…...bridgingthecaregap*手术治疗不易切除干净易复发预后差儿童预后更差治疗©ContinuingMedicalImplementation…...bridgingthecaregap*横纹肌肉瘤©ContinuingMedicalImplementation…...bridgingthecaregap* 儿童多发 肿瘤发展快恶性程度高 眶上部好发鼻上象限眼睑 上睑下垂眼睑水肿 眼球向下方移位 眼球运动障碍 视力障碍临床表现©ContinuingMedicalImplementation…...bridgingthecaregap*CT扫描 形状不规则 边界不锐利或不圆滑不均质 明显增强 可见骨破坏邻近结构破坏MRI扫描 T1WI中等或中低信号 T2WI高信号强度©ContinuingMedicalImplementation…...bridgingthecaregap*放疗和化疗结合的综合治疗放射剂量45~60Gy化学药物长春新碱、环磷酰胺手术治疗眶内容切除术治疗©ContinuingMedicalImplementation…...bridgingthecaregap*©ContinuingMedicalImplementation…...bridgingthecaregap*©ContinuingMedicalImplementation…...bridgingthecaregap*