斜视术中不同麻醉方式对眼心反射影响的观察

目的探讨斜视手术中不同的麻醉方式眼心反射发生率的差异及其临床意义。方法将84例斜视患者根据手术需要分为局麻组和全麻组,两组患者再随机分为传统麻醉组及传统麻醉联合球后麻醉组,记录勾取眼外肌前后心率变化,按照不同的麻醉方式对眼心反射发生的阳性率进行了临床观察。结果全麻患者眼心反射发生的阳性率明显低于局麻,无论患者是全麻还是局麻,球后麻醉均可有效降低眼心反射的发生率,术后呕吐的发生率也相对较低。结论在传统麻醉的基础上联合球后麻醉可以减少眼心反射的发生,有效提高斜视手术安全性。     

球后麻醉及阿托品预处理对小儿斜视手术眼心反射的影响

目的:比较全身麻醉、全身麻醉联合球后麻醉或阿托品三种麻醉方法对小儿斜视手术眼心反射(oculocardiac reflex,OCR)发生率的影响.方法:将2015-03/2016-03在我院行斜视矫正手术并采用全身麻醉的5~13岁患者92例166眼纳入研究,随机分为全身麻醉组29例55眼、全身麻醉+球后麻醉组31例54眼、全身麻醉+阿托品组32例57眼;全身麻醉组采用静脉注射丙泊酚2 mg/kg、芬太尼1 mg/kg和阿曲库铵0.5 mg/kg.全身麻醉+球后麻醉组于全身麻醉基础上球后注射20 g/L利多卡因2 mL.全身麻醉+阿托品组于全身麻醉基础上于术前加用静脉注射阿托品0.15 mg/kg.手术期间牵拉眼外肌所造成的最低心率低于心率基线值的10%以上或出现心律失常即为OCR阳性.记录术前心率基线值,术中手术时间、麻醉时间及术中OCR发生的肌肉数,术后随访6 mo并记录眼球正位例数.结果:全身麻醉+球后麻醉组的OCR发生率最低(20%),其次为全身麻醉+阿托品组(22%),两种麻醉方法OCR发生率均低于全身麻醉组(58%).三种麻醉方法在麻醉时间、手术时间、心率基线值以及手术后眼位正位率方面无统计学差异(P>0.05).结论:小儿斜视全身麻醉手术联合球后麻醉或阿托品预处理,可有效地降低术中OCR的发生率,能够为斜视患儿提供更安全的手术保障.     

喉罩全麻下术中唤醒在斜视矫正手术中的应用

目的 探讨喉罩全麻下术中唤醒用于斜视矫正手术的可行性.方法 全麻下行斜视矫正手术169例,随机分为术中唤醒组和无术中唤醒组(对照组).两组患者均在喉罩插管全身麻醉下行斜视矫正手术.术中唤醒组术中缝合固定肌肉时先打活结,保留缝线,唤醒后检查眼位,若为正位,结束手术;若为欠矫或过矫则再次麻醉,调整手术量,直至眼位正位.无术中唤醒组(对照组),按照术前设计的手术方案进行常规手术.结果 两组比较,术中唤醒组87例中,84例(96.55％)唤醒后能安静合作,3例(3.45％)唤醒后不能配合检查放弃调整.无唤醒组82例麻醉及手术顺利.术后1周,唤醒组正位率为98.85％,无唤醒组正位率为91.46％,两组间比较x2=5.108,P=0.030,差异有统计学意义;术后1年,唤醒组正位率为95.4％,无唤醒组正位率为85.37％,两组间比较x2 =4.961,P =0.035,差异有统计学意义.结论 全麻术中唤醒用于斜视矫正手术安全有效,术中唤醒时患者对喉罩耐受性好,眼位调整顺利,可以提高斜视手术的的成功率.     

62例斜视手术眼心反射观察

报道了心电监护下６２例斜视手术中的心电图所见。其中４０例为氮胺酮全麻，术前肌注阿托品，眼心反射阳性率为２２．６％。局麻２２例，用２％利多卡因局麻，加０．５％地卡因表面麻醉，眼心反射阳性率为８３．７％。全麻眼心反射严重程度明显低于局麻。说明斜视手术时，使用阿托品和氯胺酮作为术前和麻醉用药可以预防或减轻术中严重的眼心反射。     

氯胺酮异丙酚复合麻醉斜视手术眼心反射观察

目的 探讨氯胺酮及异丙酚复合麻醉下斜视矫正手术中眼心反射的影响。方法 随机选择斜视患儿120例,分为两组,A组为氯胺酮及安定复合静脉麻醉,B组为氯胺酮及异丙酚复合麻醉组。术中观察心率变化情况。结果 A组麻醉后心率加快比B组明显(P<0.05);A组有28例,而B组只有8例出现眼心反射,两组间差异具有非常显著性意义(P<0.01);B组平均手术时间短,术后苏醒快。结论 氯胺酮+异丙酚静脉复合麻醉比氯胺酮+安定麻醉效果好,眼心反射发生率低。     

不同手术方式治疗集合不足型间歇性外斜视疗效观察

目的探讨不同手术方式治疗集合不足型间歇性外斜视的疗效。方法将76例集合不足型间歇性外斜视患者,根据手术设计方式分为A、B两组,A组行双眼外直肌后徙术,B组行单眼内直肌缩短联合外直肌后徙术。术后随访,比较两组术后正位率、融合功能恢复率、立体视功能恢复率及残余性外斜视、连续性内斜视发生率。结果术后随访眼位总体正位率82.89%,A组为69.23%B组为90%,P〈0.05。术后融合功能恢复率、立体视功能恢复率、残余性外斜视和连续性内斜视发生率两组间差异均有显著性（P〈0.05）。结论采用单眼外直肌后徙联合内直截除术治疗集合不足型间歇性外斜视,术后正位率、融合功能和立体视功能恢复均优于双眼外直肌后徙术。     

Clifford Terry滑结联合可调节缝合在斜视手术中的应用

目的：探讨Clifford Terry滑结联合可调节缝合在斜视手术中的临床应用。

方法：采取回顾性研究方法,选取我院2012-05/2015-05收治的行常规斜视矫正术的45例71眼患者(对照组)与应用Clifford Terry滑结斜视矫正术45例70眼患者(研究组)为研究对象,对其术后随访1d～12mo。观察术后眼位、有无调整眼位及是否有二次手术,对术后眼位与术前眼位矫正变化情况比较分析。

结果：术后第1d Clifford Terry滑结联合可调节缝合达正位42例 67眼,1例1眼过矫,2例2眼欠矫,正位率为96%。经过Clifford Terry滑结调整松紧,正位率达到100%,研究组1、3、6、12mo术后眼位情况与对照组矫正正位效果比较未见明显差异。两组均未出现结膜裂开、肌肉滑脱、感染等术后并发症。采用Clifford Terry滑结联合可调节缝合在术中及术后早期对眼位进行微调,可即刻达到目标眼位。

结论：Clifford Terry滑结术中操作简单、术后调整缝线松紧容易操作,联合可调节缝合在斜视手术的术中及术后早期表面麻醉下即可达到目标眼位,减低术后早期二次手术的风险,优于单纯可调节缝合法。     

新鲜羊膜在儿童共同性斜视缝线调整显微手术中的应用

目的：探讨新鲜羊膜在儿童共同性斜视缝线调整显微手术中的应用疗效,为临床治疗提供指导。
　　方法：应用临床随机对照研究方法,依据眼科门诊就诊号将2010-01/2015-10在我科住院并行显微斜视矫正术的60例112眼儿童共同性斜视患者平均分为两组,A组30例58眼行直肌后徙缝线调整联合羊膜移植术, B组30例54眼行单纯直肌后徙缝线调整术,斜视矫正术后随访均≥6 mo。
　　结果：斜视患者27例48眼术后眼位需调整,眼位需调整率为42.9%。术后1mo,眼位可调整18例29眼,其中A组16例26眼,眼位可调整率为44.8%,眼位可调整量平均为2.56±0.64 mm;B 组2例3眼,眼位可调整率为5.6%,眼位可调整量平均为0.52±0.28mm,两组比较眼位可调整率及可调整量差异均有统计学意义(χ2=22.477,P<0.01;t=16.502,P<0.01)。除3例患儿术后不配合眼位调整外,其余均在术后1 mo内行不同程度的眼位调整,眼位调整后, A组27例53眼眼位正位,正位率为91.4%, B 组16例28眼眼位正位,正位率为51.9%,两组比较斜视术后正位率差异有统计学意义(χ2=21.827,P<0.01)。
　　结论：在儿童共同性斜视缝线调整显微手术过程中应用新鲜羊膜效果确切,可明显延长眼位调整时间及增加眼位调整量,提高了儿童斜视手术的可控性和成功率。     

成人水平斜视手术中局部麻醉监护指标变化的研究

目的：观察局部麻醉监护情况下成人水平斜视手术中心电图、呼吸、血氧饱和度、血压的变化情况。

方法：临床确诊为水平斜视的17例成人患者19眼36条眼外肌纳入研究。其中男10例,女7例。年龄18～71(平均32.65)岁; 外斜视14例(男8例,女6例),内斜视3例(男2例,女1例)。所有患者均进行最佳矫正视力(BCVA)、裂隙灯显微镜、间接检眼镜、角膜荧光及眼科同视机检查。术中由专业麻醉医师采用监护仪对手术采取全程密切监控。对比分析术前与局部麻醉监护术中的心电图、呼吸频率、血氧饱和度及血压的变化情况,对比内外直肌、不同性别及不同年龄组的区别。

结果：局部麻醉监护下17例成人水平斜视手术中牵拉眼外肌共36条,眼心反射发生率86.1%; 牵拉内、外直肌,眼心反射阳性率分别为100%,72.2%。眼心反射在男女性别间无统计学差异。18～30岁眼心反射阳性率明显高于31～71岁。术中呼吸频率的增高与眼心反射同步,与牵拉内外直肌、性别及不同年龄组无关。血氧饱和度无明显变化。血压在手术刚开始时出现一过性增高,首次牵拉眼内外直肌时出现一过性降低,在性别和年龄上无明显差异。

结论：在局部麻醉监护下成人水平斜视手术中,眼心反射发生率高,牵拉内直肌时100%发生; 呼吸增快与眼心反射同步; 手术即将开始时血压增高、牵拉眼内外直肌时血压降低。     

两种术式治疗基本型间歇性外斜视的比较

目的 比较双眼外直肌后徙术与单眼一退一截术治疗基本型间歇性外斜视的手术疗效.方法 对行双眼外直肌后徙(A组)和单眼一退一截(B组)手术治疗的49例基本型间歇性外斜视病例进行了回顾性分析.A组26例,B组23例.采用三棱镜加交替遮盖法测定患者戴镜注视6m和33cm调节性视标的第一眼位斜视度,根据看远斜视度手术,所有手术均由同一医生完成.术后平均随访(13.8±9.4)月,疗效评价标准以眼位≤±8Δ为正位.结果 A组眼位正位率为53.8%,B组眼位正位率为82.6%,A、B两组眼位正位率的差异具有统计学意义(x2=4.59 P=0.032),B组眼位正位率高于A组.结论 基本型间歇性外斜视应首选单眼一退一截手术.     

不同麻醉下视网膜脱离手术中的眼心反射观察

目的:观察不同麻醉方法下视网膜脱离外路手术中的眼心反射。方法:选取我科2008-06/2010-03住院患者109例109眼,随机分为对照组和治疗组,分别采用球后阻滞麻醉与静脉复合麻醉进行视网膜脱离外路手术,观察术中血压、心率、眼心反射、血氧饱和度等情况。结果:与球后阻滞麻醉比较,静脉复合麻醉下眼心反射发生率低,收缩压、舒张压及平均血氧饱和度变化较小,经统计学处理,差异有统计学意义(P<0.01)。结论:静脉复合麻醉下行视网膜脱离外路手术相对安全,并发症少,效果满意。     

Nausea and vomiting after phacoemulsification using topical or retrobulbar anesthesia

PURPOSE: To determine and compare the incidence of postoperative nausea and vomiting in patients having phacoemulsification under topical or retrobulbar anesthesia. SETTING: Department of Ophthalmology, United Christian Hospital, Hong Kong, China. METHODS: In this prospective randomized clinical trial, patients scheduled for routine phacoemulsification with posterior chamber intraocular lens implantation under local anesthesia without sedation were randomized to receive topical anesthesia or retrobulbar anesthesia. One hundred seven eyes of 107 Chinese patients were included. There were 49 patients and 58 patients of similar age and sex distribution in the retrobulbar group and topical group, respectively. Postoperative nausea and vomiting (PONV), the need for an antiemetic, and intraocular pressure (IOP) were recorded 1 day after surgery. Also recorded were the patient's preexisting risk factors for PONV (if any), fasting time, duration of surgery, and intraoperative complications or need for supplementary anesthesia or analgesia. RESULTS: The overall incidence of PONV in the entire study group was 3.7% (4 patients). No statistically significant differences in PONV were found between the 2 anesthesia techniques, although 6.1% (3 of 49) in the topical group had nausea compared with 1.7% (1 of 58) in the retrobulbar group. No significant differences were found in the fasting time, duration of surgery, or postoperative IOP between patients who had PONV and those who did not. CONCLUSIONS: Topical and retrobulbar anesthesia were associated with a low incidence of PONV in routine phacoemulsification. There were no statistically significant differences in PONV between the 2 anesthesia techniques. No significant correlation was found between the incidence of PONV and the duration of surgery, presence of complications, fasting time, postoperative IOP, or history of PONV or motion sickness.     

Preemptive analgesia in rhegmatogenous retinal detachment surgery: is it effective?

PURPOSE: To evaluate the efficacy of preemptive analgesia in surgical repair of retinal detachment (RD) using scleral buckle and cryopexy under general anesthesia. METHODS: Thirty patients who were scheduled for rhegmatogenous RD surgical repair using scleral buckle and cryopexy and who were American Society of Anesthesiologists physical status I, II, or III were included in this study. The patients were randomly divided into two equal groups. The surgery was done under general anesthesia in both groups, but in Group 2, sub-Tenon anesthesia was given as preemptive analgesia after induction anesthesia and before start of surgery. Both groups were statistically comparable as regards patient age and weight and duration of anesthesia and surgery. RESULTS: The incidences of intraoperative oculocardiac reflex and postoperative vomiting were significantly lower in Group 2 compared with Group 1 (P < 0.001 and 0.0113, respectively). The time of first postoperative analgesic dose was significantly shorter in Group 1 (46.67 +/- 18.84 minutes) compared with Group 2 (162.67 +/- 29.391 minutes) (P < 0.001). The total analgesic consumption per 24 hours was significantly higher in Group 1 compared with Group 2 (P < 0.001). The time of discharge from the hospital was significantly shorter in Group 2 (8.8 +/- 2.704 hours) compared with Group 1 (12.4 +/- 3.481 hours) (P = 0.0018). CONCLUSION: The use of sub-Tenon block as preemptive analgesia after induction of general anesthesia and before the start of rhegmatogenous RD surgical repair was effective in reducing postoperative pain and analgesic requirements compared with an unblocked group. The use of sub-Tenon block was also effective in reducing intraoperative incidence of oculocardiac reflex and postoperative incidence of vomiting.     

Combined propofol sedation with sub-Tenon's lidocaine/mercaine infusion for strabismus surgery in adults

AIMS: To evaluate the safety and efficacy of propofol sedation combined with sub-Tenon's anaesthesia for strabismus surgery in adults. METHODS: Thirty-two consecutive patients aged 31-85 years underwent strabismus surgery under general (n=16) or local (n=16) anaesthesia. In the local anaesthesia (study) group, sedation was induced with a loading dose of midazolam, fentanyl, and propofol, followed by continuous infusion of propofol, 3-6 mg/k/h to deep sedation. A nasal tube was inserted to prevent airway obstruction. Sub-Tenon's anaesthesia included infusion of a 3-4 ml mixture (50 : 50) of lidocaine 2%/mercaine 0.5%. General anaesthesia consisted of premedication with midazolam, followed by fentanyl, esmeron-bromate, propofol, and tracheal intubation. Duration of surgery and anaesthesia, intraoperative oculocardiac reflex and arrhythmias, time to discharge, postoperative pain, nausea and vomiting, and patient and surgeon satisfaction were evaluated. RESULTS: The local anaesthesia group had a significantly shorter operative and anaesthesia time, fewer episodes of oculocardiac reflex or arrythmia/bradycardia requiring treatment, fewer early or late episodes of nausea and vomiting, and less pain. The patients and surgeon in this group reported higher satisfaction. CONCLUSION: Propofol sedation with local sub-Tenon's injection of lidocaine/mercaine is recommended for the induction and maintenance of anaesthesia during unilateral or bilateral strabismus surgery in adults. The method is quick and effective, without systemic or ocular side effects.     

七氟醚、氯胺酮静吸复合麻醉与氯胺酮静脉麻醉在小儿斜视手术中的应用

目的:探讨两种麻醉方法在小儿斜视手术中的应用,并比较优缺点。方法:选择ASAI~Ⅱ级,择期接受斜视手术的患儿32例。随机分为七氟醚、氯胺酮静吸复合麻醉组(A组)和氯胺酮静脉麻醉组(B组)各16例,保留自主呼吸,为保证通气安全,均采用喉罩置入技术。记录摇头、肢体活动和血氧饱合度SpO2<95%的发生例数、眼心反射(oculocardiac re-flex,OCR)和术后呕吐(postoperati vevomiting,POV)、燥动的发生例数,睫毛反射消失时间、清醒时间等指标。结果:静吸复合麻醉组患儿接受程度高,血氧饱合度维持好,清醒快,OCR,术后燥动发生率低(P<0.05),但POV无明显差异(P>0.05)。结论:在小儿斜视手术中,七氟醚、氯胺酮静吸复合麻醉优于氯胺酮静脉麻醉。     

Vagal responses to adjustable sutures in strabismus correction.

The oculocardiac reflex is a recognized complication of ocular stimulation, precipitated most commonly by traction on the extraocular muscles. To determine the true incidence of occurrence of the oculocardiac reflex during suture adjustments, 20 patients undergoing suture adjustment were monitored for blood pressure, heart rate, and rhythm abnormalities during the suture adjustment. A control group of ten patients with strabismus were studied postoperatively for comparison. Thirteen study patients and two control patients were noted to have a vagal response (P less than .001). The most common response noted was a decrease in heart rate in 15 patients. Only two patients were symptomatic during vagal response (one patient became light-headed and another had an episode of nausea and vomiting). Suture adjustment was found to be the most common triggering event in precipitating vagal responses. Surgeons performing suture adjustment in strabismus correction should be cognizant of vagal responses so that they may properly inform patients of this possibility and take steps to minimize its occurrence.     

老年性白内障术中的眼心反射

目的探讨老年人在现代白内障摘除术中眼心反射发生情况以及术中哪些操作更易诱发眼心反射。方法由动态心电记录器分别记录术前及术中球后麻醉、软化眼球、上直肌牵引缝线、板层切开角巩膜缘、娩核及人工晶体植入等６项主要操作开始后３０～６０秒钟的心电活动。以每一手术步骤使心率减慢的次数超过其前一步骤心率的１０％为眼心反射阳性。结果３０例中有１０例（３３．３％）发生眼心反射，共发生１４次。除缝上直肌牵引缝线外，其余各项操作均记录到眼心反射。术中５例出现房性或室性早搏。结论现代白内障摘除术可影响老年人的心电活动。或许眼心反射的标准过于保守，有待重新修定。     

Additive retrobulbar anesthesia in surgery of retinal detachment with general anesthesia. Reduced postoperative pain and stress response

BACKGROUND: It has recently been shown that the pain occurring after retinal detachment surgery can be reduced by combined general and retrobulbar anesthesia. This study investigated the effect of retrobulbar anesthesia on the intra- and postoperative stress response and on postoperative pain, vigilance, nausea and vomiting. PATIENTS AND METHODS: In this prospective randomized study, 45 patients were enrolled where scleral buckling surgery for retinal detachment had been performed under general anesthesia. Bupivacain 0.5% (4 ml) was injected retrobulbarly in group I (n = 15) before surgery (preoperative) and in group II (n = 15) after surgery (postoperative), group III did not receive retrobulbar anesthesia. At different times during and after surgery, blood pressure, cortisol and glucose levels, time in the recovery unit, vigilance score, nausea and vomiting were measured and the pain score was determined. The dosages of intraoperative opioid analgetics and of postoperative pain medication were documented. RESULTS: Retrobulbar anesthesia reduces postoperative pain. Intra- and postoperative endogenous stress responses in groups I and II were reduced and the plasma levels of cortisol and glucose in group I were lower than in group II. In group I, nausea, dosages of intraoperative opioid analgetics and postoperative pain medication were reduced, the vigilance was increased and time in the recovery unit was shortened. CONCLUSIONS: The data show that combined local and general anesthesia has several advantages over general anesthesia alone, especially when the retrobulbar injection is given before retinal detachment surgery.     

舒芬太尼或芬太尼复合咪唑安定用于玻璃体手术的比较

目的:探讨舒芬太尼或芬太尼复合咪唑安定用于玻璃体手术患者术中镇静、镇痛的有效性、安全性和可行性。方法:选择择期行玻璃体手术患者120例,随机分为芬太尼组、舒芬太尼组,每组各60例。在术者开始球后神经阻滞时,缓慢注射咪唑安定0.03mg/kg,芬太尼1.0μg/kg或舒芬太尼0.15μg/kg,随之手术开始。分别于手术开始前、手术开始后15,30min和手术结束时进行镇静评分和疼痛评分。手术结束时由术者评定患者合作度,由患者评定麻醉满意度,并观察术中不良反应(眼心反射、低氧血症、躁动呻吟及恶心呕吐等)的发生情况。结果:两组患者手术开始前镇静评分、疼痛评分相比,无统计学差异(P>0.05),手术开始后15,30min,手术结束时镇静评分、疼痛评分显著高于手术开始前(P<0.05)。舒芬太尼组手术开始后15,30min镇静评分显著高于芬太尼组(P<0.05)。两组手术开始后15,30min,手术结束时疼痛评分相比,无统计学差异(P>0.05)。舒芬太尼组患者麻醉满意度、患者合作度显著高于芬太尼组(P<0.05)。舒芬太尼组患者低氧血症的发生率显著低于芬太尼组(P<0.05),其它不良反应在两组间无统计学差异(P>0.05)。结论:舒芬太尼复合咪唑安定用于玻璃体手术,镇静效果好,镇痛完善,不良反应少,患者满意度高,易于配合。