外斜V征的手术探讨

目的:探讨外斜V征的手术方法及效果。方法:分析我院2004-01/2008-12收治27例外斜V征患者的手术方法及效果。27例患者中,根据发病原因采取不同的手术方式。18例伴有下斜肌功能亢进的外斜V征患者行下斜肌减弱+外斜视矫正术;9例无下斜肌功能亢进的患者在矫正外斜视的同时行水平肌垂直移位。随访2～41mo。结果:患者27例中25例V征消失;第一眼位正位者24例,欠矫2例,过矫1例;15例患者具有不同程度双眼视功能,其中2例恢复立体视。结论:下斜肌功能亢进是外斜V征发病的主要原因,下斜肌减弱联合外斜视矫正术是有效的治疗方法;对于无下斜肌功能亢进者,在矫正外斜视的同时行水平肌垂直移位也具有确切的效果。     

伴有下斜肌功能亢进外斜V征眼外肌myogenin的研究

目的：：观察伴有下斜肌功能亢进的外斜V征患者下斜肌和内直肌中myogenin活性卫星细胞数量的变化,探讨伴有下斜肌功能亢进的外斜V征的可能发病原因。方法：将伴有下斜肌功能亢进外斜V征患者6例中切除的下斜肌及内直肌作为斜视组,行myogenin免疫组织化学染色,统计myogenin阳性染色的卫星细胞核数;角膜移植供体的下斜肌及内直肌(6例)作为对照组。结果：斜视组和对照组下斜肌中myogenin免疫染色阳性肌卫星细胞数占总细胞数比例分别为(22.7±7.03)%和(4.2±0.75)%,具有统计学差异(P<0.05)。斜视组和对照组内直肌中myogenin免疫染色阳性的肌卫星细胞数分别为(2.2±0.75)%和(4.5±1.05)%,具有统计学差异(P<0.05)。结论：首次报道伴有下斜肌功能亢进外斜V征患者眼外肌中表达 myogenin 免疫染色阳性肌卫星细胞的变化。myogenin可能是伴有下斜肌功能亢进外斜 V 征的致病因素。     

V型外斜视的临床表现和手术治疗分析

目的 探讨V型外斜视的病因、临床表现及手术治疗效果.方法 分析2004年1月至2008年6月收治1340例斜视中76例V型外斜视病例的病史资料及治疗结果.根据不同临床表现和病因,行不同的手术方式,术后进行双眼视功能训练,随访6～12月.结果 76例v型外斜视患者中,共有73例(96.05%)患者存在眼外肌功能异常,包括下斜肌功能亢进患者56例(73.68%)、上斜肌功能不足39例(51.32%)、上直肌功能减弱8例(10.53%)、下直肌功能亢进2例(2.63%)、外直肌功能亢进33例(43.42%)和内直肌功能不足4例(5.26%o术后共有65例效果满意(85.53%),第一眼位正,v征消失,59例(77.63%)通过手术和训练获得了双眼视功能.结论 V型外斜视发病原因以下斜肌功能亢进为主,根据病因选择不同的手术方式,术后配合双眼视功能训练,多能获得双眼视.     

Effectiveness of modified inferior oblique muscle belly transposition for V-pattern exotropia combined with mild to moderate inferior oblique muscle overaction

AIM: To investigate the effectiveness of a modified inferior oblique muscle belly transposition for treatment of V-pattern exotropia combined with mild to moderate inferior oblique muscle overaction. METHODS: Thirteen cases (23 affected eyes) of V-pattern exotropia with inferior oblique muscle overaction (+ or ++) who underwent the modified inferior oblique muscle belly transposition procedure were retrospectively reviewed. The amount of V-pattern, grade of inferior oblique overaction, degree of vertical strabismus, abnormal head posture, and the fovea-disc angle were evaluated before and after surgery. RESULTS: The V-pattern was corrected in all cases, and the amount of V-pattern reduced by 17.85±5.13 prism diopter (PD) on average (t=16.07, P<0.001). The surgical cure rate for mild to moderate inferior oblique muscle overaction was 87.0% (20/23). The degree of the fovea-disc angle has a mean reduction of 5.45°±2.87° (t=3.95, P=0.003) after surgery. The mean vertical deviation in 5 cases with a small-angle hypertropia (5.23±3.06 PD) in the primary position reduced by 3.15±1.86 PD (t=6.10, P<0.001). No serious complications were observed. CONCLUSION: The modified inferior oblique muscle belly transposition procedure can effectively treat mild to moderate inferior oblique overaction and relieve the V-pattern, which is safe and easy to perform.     

共同性内斜视术后继发性外斜视与斜肌功能异常的关系

目的探讨共同性内斜视术后继发性外斜视与斜肌功能异常的关系。方法 回顾性病例研究。2008年至2013年在四川大学华西医院眼科接受手术治疗的26例共同性内斜视术后继发性外斜视患者纳入研究,分析斜肌功能异常在发病因素中的作用。结果 26例中14例发生了新发的斜肌功能异常,包括上斜肌功能亢进8例次、下斜肌功能不足2例次、下斜肌功能亢进6例次、上斜肌功能不足3例次。继发性外斜合并A-V征的8例,其中合并A征5例,V征3例。结论 共同性内斜视术后发生的继发性外斜视可能与未矫正或新出现的斜肌功能异常相关。     

209例A-V型斜视的临床表现和手术治疗

目的探讨A-V型斜视的病因、临床特点、手术矫正效果及手术方式。方法分析209例A-V综合征患者的临床表现、手术方式及治疗效果;所有患者依据是否伴有斜肌功能异常、原在位水平斜视及双眼单视功能情况行斜肌减弱术或/和水平肌手术,术后观察眼位、斜肌功能及双眼单视功能,随访3～24月,平均12月。结果A-V型斜视占同期斜视患者29.9%;其中,V型外斜占55.8%,A型外斜占9.1%,V型内斜占29.1%,A型内斜占6%;术后178例（85.1%）正位,192例（91.8%）A-V征消失,术后获得立体视功能者160例（76.5%）,包括术前16例具有立体视患者。结论A-V型斜视是一种常见的斜视类型,斜肌功能异常是发病的主要原因,原在位常合并水平斜视;根据是否伴有斜肌功能异常及双眼单视功能情况选择手术方式,多可获得较为满意的效果。     

Factors influencing the outcome of strabismus surgery in patients with exotropia.

PURPOSE: To determine the factors associated with favorable and less favorable outcomes in strabismus surgery for treatment of exotropia and to show the factors influencing the efficacy of the surgical procedure. METHODS: Case files of 225 patients with a diagnosis of primary exotropia were evaluated. Information about patient age at onset of deviation, patient age at surgery, interval between onset and surgery, preoperative deviation, refractive errors, degree of anisometropia, visual acuity, presence of amblyopia, presence of an A- or a V-pattern, amount of surgery performed, type of exotropia (intermittent or constant), and existence of binocular single vision before surgery were obtained and evaluated using multiple regression analysis. RESULTS: Preoperative deviation and refractive errors were proved to be significant factors influencing a favorable outcome in patients with surgically treated exotropia (r(2) = 0.12, P <.001, and r(2) = 0.07, P <.001 respectively). Preoperative deviation, amount of surgery performed, and refractive errors shifting toward myopia significantly influenced the efficacy of the surgery performed (r(2) = 0.31, 0.06, and 0.025, respectively). CONCLUSION: Special care should be paid to refractive errors in patients with exotropia before determining the amount of surgical intervention.     

Anterior and nasal transposition of the inferior oblique muscles in patients with missing superior oblique tendons.

INTRODUCTION: Patients with missing superior oblique (SO) tendons present with overelevation/underdepression in adduction. Unilateral cases often exhibit abnormal head postures, whereas in bilateral cases, there may be a marked V-pattern with upgaze exotropia. These patients may have craniosynostosis. METHODS: Nine children with unilateral (n = 2) or bilateral (n = 7) absent SO tendons underwent anterior and nasal transposition of the inferior oblique (IO) muscles, some in combination with horizontal rectus recession for horizontal strabismus. They were evaluated 6 to 46 months postoperatively for alignment and oculomotor examination. Cyclodeviations were not evaluated in most children. RESULTS: Postoperatively, all patients improved. Both unilateral cases were orthotropic with no abnormal head posture. In the bilateral cases, vertical deviation in adduction and exotropia in upgaze had largely cleared, although some symptoms remained, most notably vertical deviation in side gaze (3 patients) and V-pattern esotropia in downgaze (2 patients). A patient missing both SO tendons as well as the left superior rectus muscle, who had the anterior and nasal transposition on the right side only, remained with 25(Delta) left hypotropia. CONCLUSIONS: Anterior and nasal transposition of the IO muscle reduces overelevation in adduction and helps eliminate or reduce divergence of the eyes in upgaze, but esodeviation may persist in downgaze. This procedure was most effective in unilateral absence of the SO tendon. It is likely to benefit patients with severe congenital fourth nerve palsy in which standard IO muscle weakening procedures have been ineffective.     

伴有下斜肌功能亢进外斜V征眼外肌病理学研究

目的:观察伴有下斜肌功能亢进外斜V征患者及正常人下斜肌和内直肌的病理学改变。方法:将伴有下斜肌功能亢进外斜V征患者6例术中切除的下斜肌及内直肌作为斜视组,行HE染色,光镜下观察病理学改变,并测量肌细胞的横截面积;角膜移植供体的下斜肌及内直肌（6例6眼）作为对照组。结果:斜视组下斜肌部分肌纤维轻度肥大增粗,粗细不等,排列紊乱,走形不规则,横纹结构欠清晰;可见部分肌纤维出现核内移现象,玻璃样变性及少量胶原纤维增生。肌纤维平均横截面积为854.1±64.8μm²,与对照组（719.7±80.4μm²）无显著性差异（P>0.05）。斜视组内直肌同样发生了病理改变。除了肌纤维走形不规则,横纹结构欠清晰,部分肌纤维出现核内移现象,玻璃样变性外,主要还表现为肌纤维减少,排列疏松、紊乱,间隙变大,胶原增生较明显。其肌纤维平均横截面积为324.9±63.3μm²,较对照组（690.8±67.3μm²）明显减小（P<0.05）。结论:斜视组功能亢进的下斜肌和弱侧内直肌均发生了明显的病理改变。     

Botulinum toxin augmented bilateral lateral rectus recession versus three muscles surgery in large-angle intermittent exotropia

AIM: To report the surgical outcomes of correcting large angle intermittent exotropia in adult patients by bilateral lateral rectus muscle recession with intraoperative use of botulinum toxin and to compare the results with those of bilateral lateral rectus muscle recession and unilateral medial rectus resection. METHODS: The medical records of patients who underwent surgical correction of large angle intermittent exotropia [exotropia >50 prism dioptre (PD)] were retrospectively reviewed. Two groups of patients were identified; Group I (21 patients) had bilateral lateral recti recession augmented with intraoperative botulinum toxin A (BTA) injection into the recessed muscles and group II (30 patients) were treated by bilateral lateral recti recession with unilateral medial rectus muscle resection. Preoperative data were extracted for age, gender, refraction, type of exotropia, angle of stereopsis and angle of deviation. The main outcome measures were the postoperative angle of deviation and stereoacuity angle by Titmus test measured at the end of one year of postoperative follow up. RESULTS: By the end of the first postoperative year, 10 patients in group I (47.6%) and 20 patients in group II (66.7%) achieved esotropia/esophoria <5 PD or exotropia/exophoria <10 PD. The difference in surgical success rate was not statistically significant (P=0.1) but there was a statistically significant higher rate of undercorrection in group I (P=0.03). On the other hand, 3 patients in group I (14.3%) and 5 patients in group II (16.7%) had improved stereopsis; this difference in the sensory outcome was not statistically significant (P=0.8). In the BTA augmented surgery group, good stereoacuity and smaller preoperative angle of deviation were associated with significantly higher surgical success rate (P=0.004, 0.01 respectively). CONCLUSION: BTA augmented bilateral lateral recti recession is associated with higher rate of undercorrection as compared to bilateral lateral recti recession with unilateral medial rectus resection in the correction of large angle intermittent exotropia. The surgical success rate in BTA augmented surgery group is observed to be higher in patients with preoperative smaller angle of deviation and in patients with good stereoacuity.     

Prevalence of horizontal deviation pattern changes with measurements in extreme gazes

PURPOSE: To analyse the difference between measurement of A and V pattern strabismus at 25 degrees and extreme gaze position in esotropia (ET) and exotropia (XT). METHODS: This prospective cross-section study included 27 patients with basic horizontal strabismus associated to any deviation pattern. Mean age was 11.88+/-9.17 (6-44) years. Exclusion criteria were amblyopia, intermittent XT, noncollaboration with the exam, previous strabismus surgery, craniofacial, or spinal abnormalities. The deviations were measured with prism cover test at 6 m. Measurements were carried out in primary position, upgaze (neck flexion of 25 degrees and maximum flexion) and downgaze (neck extension of 25 degrees and maximum extension). A goniometer with a bubble level controlled the neck position. RESULTS: The most significant changes were in downgaze. The pattern size increased 4 prism dioptres (PD) or more in 56.25% of the V- and in 87.5% of the A-patterns. The mean increase was 8.00+/-6.04 PD (0-17 PD) for the A-pattern ET, 4.80+/-3.70 PD (0-10 PD) for the V-pattern XT, and 6.50+/-5.58 PD (0-15 PD) for the V-pattern XT. The only case of A-pattern XT increased 8 PD. CONCLUSION: Our results suggest that measurements in extreme up and downgazes may uncover increased deviations in a significant proportion of cases. Further studies remain necessary to determine the relevance of these findings for strabismus correction.     

Unilateral and bilateral lateral rectus recession in exotropia.

BACKGROUND AND OBJECTIVE: To evaluate the surgical results obtained by unilateral and bilateral lateral rectus recession for the correction of exotropia. PATIENTS AND METHODS: The charts of all patients with exotropia who were operated on at the Goldschleger Eye Institute at Sheba Medical Center during an 11-year period were retrospectively reviewed. Study participants all underwent a complete orthoptic and ocular examination. Twenty-five patients with moderate-angle exotropia underwent unilateral lateral rectus recession (group 1) and 38 patients with large-angle exotropia underwent bilateral lateral rectus recession (group 2). The angle of exotropia was measured by the prism and cover test. Moderate exotropia was defined as 25 prism diopters (PD) and large-angle exotropia as greater than 25 PD. RESULTS: The mean age at the time of the surgery was 10.0+/-5.2 years in group 1 and 8.5+/-8.0 years in group 2. The mean preoperative exotropia was 16.1+/-5.7 PD in group 1 and 29.6+/-14.4 PD in group 2. A mean postoperative exodeviation of 4.2+/-5.4 PD was found in group 1 and 5.8+/-13.6 PD in group 2. The success rate (deviation of < 10 PD) was 84% in group 1 and 74% in group 2. There was no incomitance in group 1. CONCLUSION: Unilateral lateral rectus recession is an effective surgical method for correcting moderate-angle exotropia with results similar to bilateral lateral rectus recession for larger exotropia angles.     

Intermittent exotropia: bilateral lateral rectus recession treatment and long term results

PurposeTo describe the long-term surgical outcomes of bilateral lateral rectus recession in patients with intermittent exotropia.MethodsRetrospective review of 18 patients diagnosed with intermittent exotropia between 1995 and 2005 who underwent surgical treatment in the Ramon y Cajal Hospital.ResultsOf the 18 patients with intermittent exotropia, 50% were basic subtype. All of them underwent bilateral lateral rectus recession, associated with a previous failed botulinum toxin injection in 8 of them. Satisfactory results (less than 10 PD orthophoria) were obtained in 68.2% of the patients after a 4.5-year follow-up period.ConclusionsBilateral lateral rectus recession is an effective and stable surgical procedure in the long-term motor control of intermittent exotropia, especially in basic subtype. Previous injection of botulinum toxin did not affect the results.     

Original papers: Effects of diagnostic occlusion of the deviated and the dominant eye in intermittent exotropia

A previous study of intermittent exotropia has shown that diagnostic occlusion of the deviating eye often could reveal a vertical deviation that had not been recorded initially. The aim of the present study was to investigate if diagnostic occlusion of the dominant eye was still more effective in this respect. In 19 patients diagnostic occlusion was performed on the deviating eye as well as on the dominant eye. In 13 patients a vertical deviation could be elicited. The size of the vertical deviation was almost the same irrespective of which eye was occluded. The horizontal deviation both for distance and near was slightly larger after occlusion of the dominant than of the non-dominant eye. The fusion capacity was increased after occlusion more often after occluding the non-dominant than the dominant eye. Anomalies such as dissociated vertical deviations and A- and V-pattern were equally well diagnosed by occlusion of either eye. For a full diagnostic setup of patients with intermittent exotropia, occlusion of each eye separately is recommended in order to elicit maximal horizontal and vertical deviation.     

大角度外斜视手术方法的探讨

目的探讨大角度外斜视安全、有效、简便的手术方法,观察手术效果。方法39例外斜视病例按照斜视度大小分为A、B、C三组,采用外直肌超常量后徙术、外直肌常量后徙加内直肌缩短术以及外直肌超常量后徙加内直肌缩短术三种术式,术后1月测量原在位斜视度。结果A组中三种术式正位率无显著性差异,B组中三种术式正位率有显著性差异,C组选用的二种术式正位率无显著性差异。结论传统的外直肌常量后徙加内直肌缩短术在眼位正位率上更具有稳定性。外直肌超常量后徙术对于一定度数内的大角度外斜视有效。随着外斜视度数的增大,可采用外直肌超常量后徙术合并内直肌缩短术。     

Cyclic esotropia and the treatment of over-elevation in adduction and V-pattern

AIM: To describe the development and treatment of V-pattern and bilateral over-elevation in adduction in patients with cyclic esotropia. METHODS: Three patients with cyclic esotropia are described in retrospect. All patients underwent bilateral medial recession, while one patient additionally had a weakening procedure of both inferior oblique muscles. RESULTS: All patients developed a V-pattern and bilateral over-elevation in adduction. After strabismus surgery, normal eye alignment with some signs of binocularity was reached in all three patients. Moreover, the over-elevation in adduction and V-pattern completely resolved. CONCLUSIONS: V-pattern and bilateral over-elevation in adduction was seen in all patients with cyclic esotropia in the stage that fusion was disrupted. Possible explanations for the origin of these patterns are discussed. Strabismus surgery aimed to correct the horizontal esotropic angle restored fusion and eliminated the vertical incommitancies in lateral gaze, and the V-pattern.     

67例Duane眼球后退综合征的临床分析

目的探讨Duane眼球后退综合征（DRS）的临床特征以及手术治疗的方法和效果。方法对67例因DRS行手术治疗的患者资料进行回顾性总结和分析,观察项目包括患者的性别和年龄、DRS类型和临床表现、手术治疗方式和效果。结果单眼受累63例,双眼受累4例。Ⅰ型内斜视35例,外斜视12例;Ⅱ型外斜视8例;Ⅲ型内斜视1例,外斜视11例。37例患者合并内转眼急速上转和（或）下转现象,其中31例为外斜视者。行单眼内直肌和（或）外直肌后徙术或双眼内直肌后徙术可改善代偿头位、眼球后退及睑裂变小体征,术后斜视度数≤10^Δ者60例（89．6％）。行患眼内直肌和（或）外直肌后徙术,可使内转眼急速上转和下转现象得到明显改善。结论不同类型DRS的临床表现不同,内转眼上、下转现象多见于DRS外斜视者。减弱内、外直肌功能可改善DRS的临床表现;外直肌后徙术是改善内转眼急速上、下转现象的主要方法;内、外直肌同时后徙术适用于眼球后退和急速上、下转现象严重者;减弱一侧直肌功能后,眼球向对侧转动的受限程度得到改善。（中华眼科杂志,2005,41：812-816）     

外直肌超常量后徙在某些大角度外斜视矫正术中的应用

目的:观察外直肌超常量后徙在某些类型大角度外斜视矫正术中的应用和效果。方法:回顾性分析了我院2006-01/2008-07在外斜视矫正术中行外直肌超常量后徙的临床病例48例,其中分开过强型外斜视29例,知觉性外斜视16例,麻痹性外斜视3例。所有病例外斜视度数均>40△。手术原则是尽量在2条肌肉上完成斜视度的矫正。分开过强型外斜视先行双外直肌超常量后徙(8.0~9.5mm),残余度数再行一眼内直肌缩短术。知觉性外斜视手术首选视力较差的斜视眼行外直肌超常量后徙(8.0~12mm)加内直肌缩短(6~8mm),若矫正不足再行对侧眼外直肌后徙术。动眼神经不全麻痹者行麻痹眼外直肌超常量后徙(12~13mm)加内直肌大量截除(10mm)。结果:末次随访时所有患者外观良好,29例分开过强型外斜视中,23例正位,6例欠矫;16例知觉性外斜视中13例正位,2例欠矫,1例过矫;3例麻痹性外斜视中,1例正位,2例欠矫。所有欠矫或过矫均在±8~±15△,均不需要二次手术。所有病例中3例分开过强型外斜视和2例知觉性外斜视出现轻度外转不足,外转时角膜缘距外眦角约2~3mm;3例麻痹性外斜视外转不足均在3~4mm。结论:外直肌超常量后徙术对大度数的分开过强型外斜视,知觉性外斜视及麻痹性外斜视效果满意,避免了损伤过多的眼外肌,增加了外斜视矫正术的一次成功率。     

The surgical management of consecutive exotropia.

PURPOSE: To review the results and techniques of surgical treatment of consecutive exotropia. METHODS: We performed a retrospective chart review of all patients who underwent surgery for consecutive exotropia in a pediatric ophthalmology practice between 1992 and 2001. Patients were excluded if follow-up lasted < 6 weeks or if exotropia was caused by other ocular disorders such as previous trauma or congenital cataracts. RESULTS: Fifty-nine patients were identified. The procedure performed in the majority of cases was unilateral lateral rectus recession and medial rectus advancement to the original insertion. Seven patients underwent bilateral lateral rectus recession, and 6 underwent lateral rectus recession combined with medial rectus resection. The mean interval between original surgery and surgery for consecutive exotropia was 14.1 years (range 4 months to 47.5 years). The mean preoperative distance exodeviation was 31.7 prism diopters (PD). Satisfactory alignment (ie, within 10 PD of orthophoria) was achieved in 36 patients (61%) at week 1 and 42 patients (71%) at final follow-up. Mean follow up was 16.0 months. Thirty-nine patients (66%) demonstrated an exodrift after surgery (mean 7.6 PD). CONCLUSION: Consecutive exotropia may occur many years, even decades, after esotropia surgery. Lateral rectus recession with advancement of the previously recessed medial rectus is an effective treatment. An exotropic drift occurs after consecutive exotropia surgery, usually within the first 6 weeks. A suitable ocular alignment immediately after surgery for consecutive exotropia is a small-angle esotropia of 5 to 10 PD.     

Surgical management of intermittent exotropia with high AC/A ratio.

BACKGROUND: A subgroup of patients with intermittent exotropia have a high AC/A ratio, which places them at risk for esotropia at near after surgical treatment of their distance deviation. METHODS: A retrospective review of six patients with intermittent exotropia and a high AC/A ratio who were simultaneously treated with lateral rectus recessions to fully correct their exotropia at distance and placement of posterior fixation sutures on both medial rectus muscles in hopes of preventing an esotropia at near after surgery. RESULTS: Despite the persistence of a high postoperative AC/A ratio as assessed by the gradient method, five of six patients achieved stable postoperative alignment at distance and near without bifocals. One patient required postoperative bifocal correction for intermittent esotropia at near. CONCLUSION: In patients with intermittent exotropia and a high AC/A ratio, posterior fixation of the medial rectus muscles at the time of lateral rectus recessions enables the surgeon to fully correct the distance deviation and minimizes the risk of postoperative esotropia at near.