下斜肌减弱术在先天性麻痹性垂直斜视治疗中的应用

目的探讨下斜肌减弱术在不同类型先天性麻痹性垂直斜视治疗中的效果及手术选择的基本原则。方法分析近2年行手术治疗的先天性麻痹性垂直斜视患者65例(82眼),根据垂直斜视的度数分别行下斜肌截腱术,下斜肌后徙转位前徙术和下斜肌后徙转位前徙联合上下直肌徙后术。结果垂直斜视的治愈好转率达89.1%,行断腱术者60眼,平均矫正8.33±4.25°;转位术18眼平均矫正13.45±5.91°;联合术4眼,平均矫正22.00±9.79°。术后46例代偿头位改善或消失,66眼下斜肌功能亢进改善或消失;术后出现同时视者22例,建立融合功能者5例,获得立体视觉者3例。结论下斜肌减弱术是治疗先天性麻痹性垂直斜视的首选术式,该术式简单易行,疗效可靠,术后早期疗效明显,有一定促进双眼单视恢复的功能。     

伴下斜肌亢进的分离性垂直偏斜的手术治疗

目的探讨伴下斜肌亢进的分离性垂直偏斜（DVD）的手术方式及效果分析。方法回顾性分析28例合并下斜肌亢进DVD手术方式,原在位垂直斜度较小选择单纯下斜肌转位术;大度数垂直斜视行下斜肌后徙联合同侧上直肌后徙术。三棱镜加遮盖法检查垂直斜度,反复检查3次,取平均值;下斜肌亢进分＋1～＋4;术后随访1个月至3年。结果术前下斜肌亢进28例（41只眼）,其中双眼13例;亢进＋1,4只眼;＋2,20只眼;＋3,16只眼;＋4,1只眼。下斜肌亢进均得到矫正。单纯下斜肌转位22例（30只眼）,单眼14例,双眼8例。近期满意率85．71％。远期满意率71．42％。下斜肌后徙＋同侧上直肌后徙术6例（15只眼）,双眼5例,单眼1例;双眼5例中4例满意,1例好转,其中2例术后出现轻度上转受限;单眼1例,效果满意,但术眼出现轻度上转受限,睑裂变小。结论伴有下斜肌亢进DVD垂直斜度较小时下斜肌转位术效果良好;垂直斜度较大需行下斜肌减弱＋同侧上直肌后徙术,上转肌同时减弱术,双眼手术比单眼安全。     

67例V型斜视的手术探讨

目的 探讨V型斜视的临床特征及不同手术方法及效果.方法 回顾性分析了67例V型斜视的手术治疗.其中外斜V征46例,内斜V征21例,依据是否伴有下斜肌功能亢进及亢进程度,行下斜肌减弱术或水平直肌垂直移位术,所有患者按原在位水平偏斜度常规矫正水平斜视.观察手术前后的眼位、斜肌功能和双眼视觉.结果 67例手术中,49例行下斜肌后徙术或后徙转位术,术后43例上、中、下均正位,V征消失;术前无下斜肌功能亢进或下斜肌功能亢进"+"者13例,行水平直肌垂直移位术后11例正位,V征消失.67例患者术后19例恢复双眼视.结论 下斜肌后徙,后徙转位术适用于下斜肌功能亢进(++)-(+++)的V征,水平直肌垂直移位术适用于无下斜肌功能亢进或下斜肌功能亢进+的V征,应根据下斜肌功能亢进程度选择手术方式.     

下斜肌减弱术治疗下斜肌功能亢进

目的观察下斜肌减弱术治疗下斜肌功能亢进的治疗效果。方法下斜肌功能亢进92例,以正前方的垂直斜视度为依据:斜视度在15△以内者(43例),采用下斜肌截除术;斜视度在15△以上者(49例),采用下斜肌截除术联合对侧眼下直肌后徙术或同侧眼上直肌后徙术。结果79例(85.87%)原位眼垂直斜视度得到矫正,68例代偿头位患者中62例(91.18%)代偿头位消失或减轻。结论根据正前方的垂直斜视度采用不同的下斜肌减弱术,可获得较好的临床治疗效果。     

先天性上斜肌麻痹手术疗效分析

目的　探讨先天性上斜肌麻痹的有效手术治疗方法 ,总结临床经验。方法　我院近 3年手术治疗的先天性上斜肌麻痹患者 1 43例 ,根据患眼下斜肌亢进程度和垂直斜度大小选择下斜肌徙后术、下斜肌断腱术、下斜肌前转位术 ,以及联合对侧眼下直肌或患眼上直肌手术。结果　 1 43例患者术后随访 1～ 3 6个月 ,治愈 1 0 7例 ,占 74 83 % ;好转 2 9例 ,占 2 0 2 8% ;无效 7例 ,占 4 89%。结论　先天性上斜肌麻痹手术术式选择按减弱直接拮抗肌和配偶肌 ,加强麻痹肌及间接拮抗肌原则进行。手术根据患眼下斜肌亢进程度和垂直斜度大小选择下斜肌徙后术、下斜肌断腱术、下斜肌前转位术 ,以及联合对侧眼下直肌或患眼上直肌手术 ,可取得较好的效果。术后随眼位矫正和视功能恢复 ,代偿头位逐渐好转或消失 ,年龄越小 ,恢复越快。有手术指征者应尽早手术     

下斜肌后徙转位术治疗分离性垂直斜视

目的探索伴有下斜肌亢进的分离性垂直偏斜的有效手术方式。方法对54例95眼伴有下斜肌亢进的DVD患者应用下斜肌后徒转位法。依据上斜程度确定下斜肌新附着点的位置。上斜小于6△16眼转位到下直肌止端水平后1mm;上斜7～11△45眼,转位到下直肌止端水平;上斜大于11△34眼,前移到下直肌止端前1mm或2mm(1mm25眼,2mm9眼)其中1例单眼上斜50～80△者联合同侧上直肌后徙6mm,对合并水平斜视者,则采用水平直肌后徙和缩短术同时矫正水平斜视。结果术后满意者93眼(97.89%),好转者2眼(2.11%),无1例无效者。95眼术后下斜肌亢进均消失,无1例上转受限者。结论下斜肌后徒转位术是治疗伴有下斜肌亢进分离性垂直斜视的有效手术方式。     

下斜肌前转位术治疗双眼先天性上斜肌麻痹临床观察

目的:探讨下斜肌前转位术治疗双眼先天性上斜肌麻痹伴下斜肌亢进的临床疗效。方法:对28例双眼垂直偏斜角为15△～30△的先天性上斜肌麻痹患者行下斜肌前转位手术治疗,合并水平斜视者同期手术矫正,观察手术前后其原在位垂直斜视度、头位变化、下斜肌亢进程度。结果:患者26例垂直偏斜角为15△～25△的患者行下斜肌前转位术,全部治愈,代偿头位消失。1例双眼垂直偏斜角为>25△的患者行双下斜肌前转位术后,残余部分双下斜肌功能亢进,欠矫度为7.8△,行二期双下直肌后徙术后,垂直斜视好转,代偿头位明显改善。1例伴外斜视患者同时行水平肌手术后出现眼球外展轻度受限,能过中线。结论:对伴双眼下斜肌功能亢进,原在位垂直斜视度较大的先天性上斜肌麻痹患者,行双眼下斜肌前转位手术矫正有操作简便、疗效显著、复发率低等优点,且适用于双眼不等量下斜肌功能亢进患者,值得推广。     

伴斜肌功能亢进A-V综合征58例临床分析

目的探讨伴斜肌功能亢进A-V综合征的临床特征及手术矫正效果。方法58例患者均行下斜肌或上斜肌减弱术(下斜肌切断或部分切除术、上斜肌断腱术)+水平肌手术,观察术前术后眼位及斜肌功能。结果下斜肌、上斜肌减弱术治疗58例伴斜肌功能亢进A-V综合征患者,手术后A-V征均得到矫正,9例伴代偿头位有不同程度改善,4例术后尚残留；轻度水平斜视,疗效满意。斜肌减弱术是治疗伴斜肌功能亢进A-V综合征的有效手术方式。     

三种下斜肌转位术治疗分离性垂直斜视疗效观察

目的观察三种下斜肌转位术治疗分离性垂直斜视的手术疗效,探讨治疗DVD的最佳手术方法。方法伴有下斜肌功能亢进的DVD患者75例,根据手术方式分为3组:单纯下斜肌转位术组、下斜肌截除联合转位术组、下斜肌截除联合前徙并转位术组。观察3组术后1个月、3个月及6个月的眼位、下斜肌运动、代偿头位及并发症情况。结果 3组患者术后下斜肌亢进均消失;代偿头位均不同程度改善;单纯下斜肌转位术组和下斜肌截除联合转位术组术后效果良好者23例(92%)、下斜肌截除联合前徙并转位术组术后效果良好者24例(96%),3组间疗效无明显差异,P<0.05。单纯下斜肌转位术无明显的睑裂变化及上转受限,而联合截除术式有少部分患者出现睑裂变小和眼球上转受限。结论单纯下斜肌转位术可矫正15△~25△的垂直斜视,且术后眼球上转受限和睑裂变化也不明显,是伴有下斜肌功能亢进DVD的首选方法。     

单眼上斜肌麻痹伴同侧上直肌亢进或挛缩综合征手术治疗

目的观察下斜肌减弱联合同侧上直肌后徙手术治疗单眼上斜肌麻痹伴同侧上直肌亢进或挛缩综合征的临床疗效和安全性。方法2013年5月至2016年2月在沈阳市第四人民医院眼科,临床确诊为单眼上斜肌麻痹伴同侧上直肌亢进或挛缩综合征患者12例,所有患者第一眼位垂直斜视度≥15△,麻痹眼侧歪头试验阳性,向麻痹眼方向注视时垂直斜视度比第一眼位〉5△,上方所有注视眼位均上斜,对侧眼上斜肌功能过强。所有患者均为初次手术治疗,手术将下斜肌后徙于下直肌颞侧止端后3mm,上直肌后徙3-5mm,合并水平斜视者同时予以矫正。结果术前患者均有代偿头位,中度9例,重度3例;术后所有患者代偿头位均有改善,头位消失者6例,轻度倾斜者4例,中度倾斜者2例;术前第一眼位垂直斜视度（24．8±5．2）△,术后（6．0±2．8）△;术后歪头试验10例阴性,2例轻阳性;术后术眼有轻度上转受限,无双眼复视。结论下斜肌减弱联合同侧上直肌后徙手术是治疗单眼上斜肌麻痹伴同侧上直肌亢进或挛缩综合征可选择的手术方式,可以有效改善代偿头位和垂直斜视,未引起明显上转受限。     

Apparent contralateral inferior oblique muscle overaction after unilateral inferior oblique muscle weakening procedures.

BACKGROUND: Unilateral inferior oblique muscle weakening surgical procedures often lead to the appearance of inferior oblique muscle overaction in the contralateral eye. The purpose of this study was to determine how different types of unilateral inferior oblique muscle procedures affect the apparent function of the inferior oblique muscle in the contralateral eye. METHODS: A computer search was performed to locate all patients on the pediatric ophthalmology service at the Wilmer Ophthalmological Institute who underwent a unilateral inferior oblique muscle weakening procedure from 1980 to 1994. Only patients with a diagnosis of primary inferior oblique muscle overaction were included in the study. RESULTS: Fourteen patients met the inclusion criteria. One patient had undergone an anterior transposition of the inferior oblique muscle, seven patients had undergone a 10 mm recession of the inferior oblique muscle, and six patients had undergone a myectomy of the inferior oblique muscle. Before the operation,there was no difference in the inferior oblique muscle function of the contralateral eye among the three groups. However, after the operation apparent inferior oblique muscle overaction developed more frequently and to a greater degree in the contralateral eye among patients in the anterior transposition and 10 mm recession groups than among patients in the myectomy group. CONCLUSION: Either anterior transposition or 10 mm recession of the inferior oblique muscle may limit elevation in abduction in the eye on which inferior oblique muscle surgery was performed. The limitation of elevation in abduction may create apparent inferior oblique muscle overaction in the contralateral eye.     

Comparison of inferior oblique muscle weakening by anterior transposition or myectomy: a prospective study of 20 cases

BACKGROUND/AIMS: Among the various weakening techniques of inferior oblique muscle overaction, the most commonly used techniques include myectomy, recession, and anterior transposition. Anterior transposition and myectomy were compared to evaluate the surgical results in inferior oblique overaction. METHODS: 20 children with bilateral +3 overacting inferior oblique muscles underwent a prospective randomised study by which the anterior transposition procedure in one eye was compared with the myectomy procedure in the other eye. RESULTS: Postoperative follow up averaged 2 years. The success rates in two surgical procedures were 85% for the anterior transposition and 25% for the myectomy (standard of success was based on zero inferior oblique overaction). In only one case did the anterior transposition tend to limit the elevation of the eye in the midline, adduction, and abduction. Anterior transposition produced hypotropia at the primary position in only one case. Most eyes that underwent myectomy (75%) showed apparent residual overaction. CONCLUSION: The anterior transposition appeared to be more effective in eliminating the overaction of inferior oblique muscle than the myectomy.     

Inferior oblique muscle fixation to the orbital wall: a profound weakening procedure.

INTRODUCTION: Recurrent or persistent inferior oblique overaction may occur after inferior oblique (IO) recession or anterior transposition. IO nasal and temporal myectomy and anterior-nasal transposition may result in undesirable IO palsy, exotropia, incyclotorsion, or limitation of elevation. Previous studies have shown that a rectus extraocular muscle may be profoundly weakened if the muscle insertion is reattached to adjacent orbital periosteum. We describe a reversible profound weakening surgical procedure of the IO muscle. METHODS: A total of 10 consecutive subjects with V-pattern strabismus and/or IO overaction underwent IO orbital fixation procedure by attaching its insertion to the periosteum of the lateral orbital wall. One subject was not included because short follow-up. Five subjects with persistent IO overaction after IO anterior transposition underwent bilateral IO orbital wall fixation. Four subjects with no previous IO surgery underwent unilateral IO orbital wall fixation; 3 of these 4 subjects had superior oblique palsy with a large vertical deviation in primary position and 1 had a V pattern with asymmetric IO overaction. RESULTS: V pattern significantly improved from 22(Delta) preoperatively to 7(Delta) postoperatively (p = 0.002). IO overaction improved from 2.5 (range, + 1.5 to + 4) to 0.1 (range, -2 to +3) postoperatively (p < 0.001). Six of 9 subjects had no residual overelevation in adduction postoperatively. Unilateral IO orbital fixation corrected 7(Delta) of vertical deviation in the primary position and 23(Delta) in adduction. Mean postoperative follow-up was 5 months. CONCLUSIONS: IO orbital fixation has a profound weakening effect on the IO muscle. Advantages of this procedure include reversibility and that it can be converted into another form of weakening procedure, if required.     

Marginal myotomy of the minimally overacting inferior oblique muscle in asymmetric bilateral superior oblique palsies.

PURPOSE: We report the surgical results of marginal myotomy of a minimally overacting inferior oblique muscle in conjunction with traditional recession or myectomy of the greater overacting inferior oblique muscle in 10 patients with asymmetric bilateral superior oblique palsies and asymmetric inferior oblique overaction. METHODS: Ten consecutive patients with bilateral superior oblique palsies had a hypertropia in primary position (5-28 PD) and unequal inferior oblique overaction (0 to +2 in the lesser overacting inferior oblique muscle, +2 to +4 in the greater overacting inferior oblique muscle). Reversal of the hypertropia was noted in ipsilateral oblique upgaze. All patients underwent a recession or myectomy of the greater overacting inferior oblique muscle and a marginal myotomy of the lesser overacting inferior oblique muscle. RESULTS: Seven patients had no vertical deviation in primary position, 2 patients had a residual hypertropia of 2 to 3 PD, and 1 patient had a residual hypertropia of 8 PD. The abnormal head position present preoperatively in 8 patients was eliminated or greatly improved after surgery. Postoperatively all but 1 inferior oblique overaction was graded as 0 to trace. Mean follow-up time was 19 months (range, 1.5-68 months). CONCLUSIONS: In bilateral superior oblique palsies with asymmetric inferior oblique overaction, a mildly overacting inferior oblique muscle can be corrected by marginal myotomy, combined with a recession or myectomy of the greater overacting inferior oblique muscle. This procedure can reduce or eliminate the hypertropia in primary position while minimizing the possibility of residual inferior oblique overaction.     

Nasal myectomy of the inferior oblique muscles for recurrent elevation in adduction.

PURPOSE: Recurrence of inferior oblique overaction (IOOA) after recession or anterior transposition of the inferior oblique (IO) muscles is a common problem. We have been treating such cases by nasal myectomy of the IO, where a segment of approximately 5 mm is removed from the nasal portion, leaving the temporal portion of the IO with its insertion and its ancillary origin, the neurofibrovascular junction, intact. Here we report long-term findings on this procedure. METHODS: Records were analyzed on 72 eyes belonging to 40 patients with recurrent IOOA of grade +1 or more, who received nasal myectomy of the inferior oblique (NMIO) in one (8 cases) or both (32 cases) eyes, and who had a minimum of 3 months follow-up. RESULTS: At follow-up (range 3.6 months to 12 years; median 26 months), 27 patients (68%) showed no IO overaction, whereas 11 (28%) showed improvement of at least one grade point and 2 (5%) showed no improvement. Of the patients with residual IO overaction, three received additional surgery: in two of these patients IO overaction was subsequently eliminated while no additional follow-up was available for the third patient. The effects of NMIO on dissociated vertical deviation were variable. CONCLUSION: In 95% of these patients nasal myectomy of the IO resulted in reduction and in many cases elimination of IO overaction. An advantage of this procedure is that the temporal portion of the muscle, with its ancillary origin and insertion, is preserved.     

Combined bilateral superior rectus muscle recession and inferior oblique muscle weakening for dissociated vertical deviation.

PURPOSE: Dissociated vertical deviation (DVD) is a common disorder that is often difficult to treat satisfactorily with extraocular muscle surgery. Weakening both elevators in a single eye is uncommonly performed because of possible severe upgaze deficiency or chin-up head posture postoperatively. METHODS: A retrospective review of medical records was performed that yielded 14 patients who had undergone bilateral superior rectus muscle recessions (mean 8.1 mm, range 5-10 mm) and bilateral inferior oblique muscle recession, myectomy, or anterior transposition in the treatment of DVD. Three additional patients with asymmetric inferior oblique muscle overaction or true hypertropia in primary gaze position were identified who had bilateral superior rectus muscle recessions combined with unilateral inferior oblique muscle weakening. RESULTS: Mild-to-moderate elevation deficiencies were common postoperatively but never exceeded -2 up-gaze limitation (scale 0 to -4) except in the immediate postoperative period and were not associated with persistent chin-up head posturing. Cosmetically objectionable upper eyelid retraction occurred in one patient after re-recession of a superior rectus muscle but before inferior oblique muscle surgery. Only three patients undergoing four vertical muscle surgeries had residual DVD >10 PD in primary gaze position, and none exhibited manifest dissociated strabismus warranting further treatment. CONCLUSION: Bilateral superior rectus muscle recession of up to 10 mm combined with inferior oblique muscle weakening appears to be a safe surgical approach in the management of patients with large angle or recurrent DVD. Our data further suggest that simultaneous four vertical muscle surgery may be preferred in some patients to weakening the superior rectus or inferior oblique muscles alone.     

“Inverted Brown pattern”: A tight inferior oblique muscle masquerading as a superior oblique muscle underaction—clinical characteristics and surgical management

PURPOSE: To characterize, and evaluate the surgical management of, patients with unilateral deficiency of depression in adduction, suggesting superior oblique muscle underaction, without significant ipsilateral inferior oblique muscle overaction. METHODS: Such patients were identified who also had received either ipsilateral inferior oblique (IO) muscle weakening or contralateral inferior rectus muscle recession. Their histories, motility patterns, intraoperative findings, types of strabismus surgery, and postoperative results were analyzed. RESULTS: Twelve patients were identified with unilateral deficiency of depression in adduction, with no or minimal ipsilateral IO muscle overaction. Three of these patients (25%) had previously had surgery for Brown syndrome. Four (33%) had prior orbital floor trauma. On exaggerated forced duction testing recorded for nine patients, a tight IO muscle was recorded in 78%, with no laxity of the superior oblique tendon. Four patients (33%) underwent contralateral inferior rectus muscle recession, but in all four the deficiency of depression in adduction recurred. The other eight (67%) had an IO muscle weakening procedure and achieved overall improvement of ocular alignment. Nine subsequent patients with a similar pattern of misalignment were each managed with an IO weakening procedure, with good results. CONCLUSIONS: This motility pattern, which we are calling an "inverted Brown pattern," is caused by a tight or inelastic IO muscle. In such cases, IO muscle weakening yields better results than contralateral inferior rectus muscle recession, even though there is no significant IO muscle overaction preoperatively.     

Effect of graded anterior transposition of the inferior oblique muscle on versions and vertical deviation in primary position.

INTRODUCTION: There are various methods for weakening the inferior oblique muscle; here we describe the results of a graded anterior transposition. METHODS: Charts of 21 children (37 eyes) who underwent graded anterior transposition of the inferior oblique muscle were reviewed. Graded anterior transposition consisted of reinsertion of the inferior oblique muscle at various points along the temporal aspect of the inferior rectus muscle; the more severe the overaction, the more anterior the placement of the new insertion. In all cases the new inferior oblique insertion line was oriented parallel to the inferior rectus muscle axis. We analyzed the preoperative to postoperative change in inferior oblique overaction (versions) and vertical alignment in primary position. RESULTS: Postoperatively, 18 of 21 patients had normal versions, 2 patients had -1 underaction of 1 eye, and 1 patient had +1 overaction of both eyes. Eleven patients (15 eyes) had a preoperative vertical deviation in primary position of 4 PD or more. Three of these patients had unilateral congenital superior oblique palsy and a preoperative hypertropia of 20 PD. They underwent unilateral graded anterior transposition with a mean postoperative vertical change of 18 PD. Three patients had asymmetric primary inferior oblique overaction with true hypertropia, 1 patient had amblyopia and primary inferior oblique overaction, and 4 patients had dissociated vertical deviation associated with inferior oblique overaction. All patients had improvement after surgery, with no significant vertical deviation in primary position. CONCLUSIONS: Graded anterior transposition of the inferior oblique muscle is effective in normalizing versions and correcting vertical deviations in primary position.     

下斜肌前置移位治疗伴有下斜肌亢进的分离性垂直偏斜

目的:观察下斜肌前置移位治疗伴有下斜肌亢进的分离性垂直偏斜(dissociated vertical deviation,DVD)。方法:下斜肌前置移位于下直肌附着点颞侧前2mm或下直肌附着点颞侧成一直线处,同时矫正水平斜视。结果:患者8例11眼中,术前6眼DVD程度是1+,术后DVD消失;术前3眼DVD程度是2+,术后2眼垂直斜视消失,1眼DVD程度为1+;术前2眼DVD程度是3+,术后1眼DVD程度为1+,1眼为2+。所有患者下斜肌均不亢进。结论:下斜肌前置移位是治疗伴有下斜肌亢进的DVD的有效方式,无明显副作用。     

Comparison of anterior transposition and recession of the inferior oblique muscle in unilateral superior oblique paresis

PURPOSE: Both anterior transposition and graded recession have been shown to be effective procedures in weakening the inferior oblique muscle. Anterior transposition may work in part by converting the inferior oblique muscle from an elevator to a depressor of the globe. In theory, this would be useful in treating the inferior oblique overaction associated with superior oblique paresis. We compared inferior oblique recession and anterior transposition for the surgical correction of Knapp's class III unilateral superior oblique paresis. METHODS: Four patients underwent 14 mm recession, and five underwent anterior transposition of the inferior oblique muscle for the hypertropia in superior oblique paresis. Prism cover test measurements were made in all cardinal fields of gaze and were compared before and after operation between the two groups. RESULTS: The mean preoperative hyperdeviation in the primary position was 12 prism diopters in the recession group and 15 prism diopters in the anterior transposition group. The mean postoperative hyperdeviation was 1 prism diopter in the recession group and 3 prism diopters in the anterior transposition group. Postoperative results in the inferior oblique field of action demonstrated a mean 3 prism diopter hypertropia in the recession group and a 2 prism diopter hypotropia in the anterior transposition group. CONCLUSIONS: Anterior transposition and graded recession gave similar results in correcting the primary position hyperdeviation in Knapp's class III superior oblique paresis. Both procedures also markedly improved the hyperdeviation in the field of action of the inferior oblique muscle and superior oblique muscle. However, anterior transposition was more likely to result in postoperative hypodeviation in upgaze.