知觉性斜视的临床特征及手术治疗

目的 观察知觉性斜视的临床特征,并探讨其手术设计原则.方法 回顾性分析99例知觉性斜视患者的临床资料,包括视觉障碍发病年龄、病因、知觉性斜视类型、屈光状态;83例患者行斜视矫正手术,手术方式首选偏斜眼超常量手术,外斜视分为预期术毕正位组和预期术毕过矫组.观察手术前后眼位情况.结果 32例知觉性内斜视患者视觉障碍全部发生在出生后5岁内,其中29例(90.63％)患者发生在生后6个月内.67例知觉性外斜视患者生后5岁内发生视觉障碍者43例(64.18％),5岁以后发生视觉障碍者24例,内/外斜视组间差异具有显著统计学意义(x2=13.24,P =0.000).53例屈光参差性弱视的屈光状态:知觉性内斜视和外斜视的健眼等效球镜分别为(-0.32 ±2.52)DS和(-1.31±2.25)DS,患眼等效球镜分别为(0.63±5.60) DS和(-1.78 ±6.34)DS,两组间差异均无统计学意义(P=0.169,P=0.181).术后随访6个月～1.2 a,27例知觉性内斜视患者末次随访时,正位19例、欠矫7例、过矫1例.知觉性外斜视中预期术毕正位组20例,末次随访时正位11例、欠矫9例;预期术毕过矫组36例,正位27例、欠矫7例、过矫2例,两组间差异有统计学意义(P=0.041).结论 知觉性斜视中屈光参差性弱视为主要原因.知觉性斜视类型与视觉障碍发病年龄有关,5岁以内视觉障碍者宜发生内斜视.知觉性内/外斜视手术设计不同,通过合理的手术治疗可以起到良好的美容效果.     

不同类型及程度弱视儿童的立体视觉

目的 了解不同类型及程度弱视儿童的立体视觉状况.设计 回顾性对比临床分析.研究对象 北京同仁医院眼科中心89例屈光不正性弱视、45例屈光参差性弱视及39例斜视性弱视儿童.方法 采用颜少明随机立体检查图和同视机三级功能检查,对三种弱视儿童分别检测其近零视差立体视锐度、交叉视差及非交叉视差立体感知度、远立体视和融合范围.主要指标 近零视差、交叉视差、非交叉视差、远立体视和融合范围.结果 屈光不正性弱视及屈光参差性弱视儿童中,轻度弱视近零视差、交叉视差均优于中度弱视(P均＜0.05);斜视性弱视儿童中,中度弱视远立体视优于重度弱视(P＜0.05);轻度、中度屈光不正性弱视、屈光参差性弱视的远融合范围均无显著性差异,中度、重度斜视性弱视的远融合范围也无显著性差异(P均＞0.05).结论 弱视影响儿童期立体视觉的发育,且随弱视程度加重而增加.对立体视觉的影响程度,屈光不正性弱视轻,斜视性弱视重,屈光参差性弱视介于二者之间.(眼科,2008,17:59-62)     

不同类型弱视的屈光状态分析

对不同类型弱视１７６５例的屈光状态进行分析，斜视弱视占５８．１％，屈光不正性弱视占２８．９％，屈光参差性弱视占１３．５％，斜视弱视中内斜视弱视占全部弱视的４２．３％，其中以调节性内斜视为最多，占内斜视中的８０％。斜视弱视中并有屈光不正者，先天性内斜视占９０％，调节性内斜视占１００％，非调节性内斜视占７２．３％。     

部分调节性内斜视术后弱视复发的治疗

目的探讨遮盖法、远距离压抑疗法对部分调节性内斜视弱视复发的治疗效果.方法对28例术前诊断为部分调节性内斜视术后弱视复发的患儿,随机分为两组,分别以遮盖法及压抑主眼看远行弱视治疗,观察治疗后3个月、6个月、1年的视力及眼位.结果遮盖法与压抑主眼看远相比,视力提高在3个月及6个月时差异有显著性(P＜0.05);在1年差异无显著性(P＞0.05).眼位变化在3个月及6个月时差异无显著性(P＞0.05);在1年差异较明显(P＜0.05).结论遮盖法与压抑主眼看远相比视力恢复快,但遮盖时间过长,部分患儿出现斜视度增加;压抑主眼看远,弱视的治疗时间长,但眼位较为稳定.对于术后两眼屈光参差不大、轻度弱视的患儿,可选择遮盖法,使治疗时间缩短;而对于术后两眼屈光参差较大、中度弱视的患儿,可选择压抑主眼看远,眼位更为稳定.     

继发性外斜视49例发病因素的探讨

目的 探究影响内斜视术后继发性外斜视发病的相关因素.方法 对2006年6月至2011年12月住院的49例内斜视术后继发外斜视的患者进行回顾性病例分析,探讨其发病的相关因素.结果 本组49例患者,内斜视的发病年龄为2～72月,平均为18.43月,4岁前发病48例(97.96％),1岁前发病29例(59.18％);内斜视术前28例患者(96.55％)表现为单眼抑制(5 m及33 cm),42例(100％)无立体视;继发性外斜视术前28例患者(57.14％)伴3Δ～25Δ的垂直斜视,平均为8.54Δ(5 m)和8.43Δ (33 cm);内斜视术前10例患者调节性集合/调节(AC/A)比率＜4(28.57％),继发性外斜视术前18例患者AC/A比率＜4(75％),两者间差异具有统计学意义(P＜0.05);继发性外斜视术前10例患者存在2.00D～5.00D的屈光参差,8例患者合并内转受限;继发性外斜视平均发生于内斜视术后4.08年,其9年内发生率为93.88％.结论 内斜视的发病年龄早,立体视功能不健全甚或无立体视,合并垂直斜视,调节性集合减弱,屈光参差及内转受限,是造成继发性外斜视发生的重要影响因素.继发性外斜视可发生于内斜视术后多年,因此术后需长期随访,至少随访4年.     

屈光参差性弱视治疗前后双眼视觉的临床观察

目的 了解屈光参差性弱视儿童治疗前及矫正视力正常后双眼视觉的状况.设计回顾性病例系列.研究对象屈光参差性弱视儿童53例.方法 对53例屈光参差性弱视儿童分别在治疗前及矫正视力≥0.9后采用颜少明<立体视觉检查图>和同视机检测其双眼视觉功能.主要指标立体视锐度、交叉视差、非交叉视差立体视觉,同时知觉、远融合范围,定性远立体视.结果 屈光参差与弱视(r=0.613)、弱视与立体视(r=0.422)及屈光参差与立体视均具有相关性(r=354).弱视患儿矫正视力正常后其近立体视锐度、交叉视差、非交叉视差立体视觉均较治疗前有显著改善,差异有统计学意义(P＜0.01).弱视患儿矫正视力正常后其同时视功能较治疗前无明显差异(P=0.37);远融合范围及远立体视均较治疗前有显著改善,差异有统计学意义(远融合范围P=0.03,远立体视P＜0.01).结论 屈光参差、弱视、立体视觉三者之间具有相关性.屈光参差性弱视影响融合和立体视觉的发育.随着视力的提高,双眼视觉有显著改善.     

屈光参差性弱视儿童视力与立体视的关系

目的探究相同屈光参差范围内不同类型屈光参差性弱视儿童的视力与立体视情况,以及视力、屈光参差类型对拥有立体视与否的影响。方法回顾性研究。收集56例屈光参差性弱视儿童和52例伴有斜视的屈光参差性弱视儿童以及20例正常儿童相应检查数据,检查包括矫正视力、屈光程度、随机点动态2阶粗糙立体视。采用多元方差分析3类儿童的视力差异,统计立体视分布情况,运用非条件logistic回归分析视力与屈光参差类型对拥有立体视与否的影响。结果单纯屈光参差性弱视儿童与伴有斜视的屈光参差性弱视儿童的视力差异无统计学意义（F=3.58,P=0.0314,校正α=0.016）。单纯及伴有斜视的屈光参差性弱视儿童粗糙立体视拥有率分别为96%,71%。在双眼视力一致的条件下,伴有斜视的屈光参差性弱视与单纯屈光参差性弱视儿童相比,拥有2阶立体视的OR估计值为0.132（95%CI：0.034~0.503）。在屈光参差类型一致的条件下,高、中双眼视力平衡度与低双眼视力平衡度相比,拥有2阶立体视的OR估计值分别为5.161（95%CI：0.868~30.675）和3.939（95%CI： 0.920~16.858）。结论相同屈光参差程度范围中不同类型屈光参差性弱视儿童的视力差异不明显;伴有斜视的屈光参差性弱视儿童立体视缺损的可能性更高,并且双眼不平衡度越高引起的立体视下降越明显。     

LASIK治疗近视性屈光参差性弱视

目的 评价准分子激光原位角膜磨镶术(laser in situ keratomileusis;LASIK)治疗近视性屈光参差性弱视的临床疗效.方法 用LASIK手术矫正8位近视性屈光参差性弱视患者,比较手术前后屈光不正的度数和立体视锐度的改变,并将术前的最佳矫正视力和术后第1天,第3天,第10天的裸眼视力以及6～9个月随访的裸眼视力和最佳矫正视力进行比较和分析.结果 术前屈光度数高眼的屈光不正的等效球镜平均为(-10.06±1.50)D,术后该眼屈光不正的等效球镜平均为(0.19±0.32)D.手术前后立体视锐度差别有统计学意义(z=-2.207,P=0.027).术前屈光度数高眼矫正视力和术后该眼矫正视力相比,差别有统计学意义(F=11.431;P=0.000).结论 LASIK手术能安全,有效地减少近视性屈光参差,提高患者的视力和立体视功能.     

不同类型弱视儿童视网膜结构和视觉诱发电位及立体视功能的差异性分析

目的:分析不同类型弱视儿童的视网膜结构和功能、视觉诱发电位及立体视功能的差异性。方法:选取2014-05/2018-05在我院眼科治疗的中度弱视儿童92例136眼为观察组(屈光参差性31例31眼,屈光不正性35例70眼,斜视性26例35眼),另选取在我院眼科检查视力正常的儿童29例58眼为对照组。采用光学相干断层扫描(OCT)成像仪检测黄斑中心凹厚度、视盘周围及各象限视网膜神经纤维层(RNFL)厚度,采用视觉眼电图检测视网膜功能变化,观察视觉诱发电位P100波幅值及潜伏期的特点,并进行立体视觉检查。结果:屈光参差性、屈光不正性弱视儿童黄斑中心凹厚度、视盘周围及各象限RNFL厚度均明显高于对照组和斜视性弱视儿童(P<0.01)。与对照组相比,屈光参差性弱视儿童视觉眼电图光峰电位偏低,光峰时间延长,屈光不正性弱视儿童中近视儿童暗谷电位偏高,Arden比和Gliern比减小(均P<0.01)。三种类型弱视儿童视觉诱发电位P100波幅值均明显低于对照组,且1°和15′空间频率潜伏期明显延迟(均P<0.01)。屈光不正性弱视儿童交叉视差、非交叉视差、近零视差、远立体视功能正常眼数显著高于斜视性弱视儿童(P<0.0167),但与屈光参差性弱视儿童上述各项指标无差异。结论:屈光参差性弱视、屈光不正性弱视儿童视网膜结构存在明显异常,且P100波潜伏期延迟;斜视性弱视对立体视功能影响最大,而屈光不正性弱视影响最小。     

影响屈光性调节性内斜视立体视锐度发育因素分析

目的分析影响屈光性调节性内斜视患者立体视锐度发育的因素。方法对100例屈光性调节性内斜视按斜、弱视常规戴镜的原则进行治疗;采用同视机测量斜视度数;用颜少明的立体视觉检查图测量近立体视锐度。结果屈光性调节性内斜视患者发病年龄越小、戴镜前斜视度越大、两眼视力差距越大,立体视锐度的发育越差。结论屈光性调节性内斜视患者的立体视锐度发育与发病年龄、戴镜前斜视度、两眼视力有关。     

Bimedial hang-back recession -- outcomes and surgical response

AIM: To report outcomes and identify factors affecting surgical response for constant esotropia using 'hang-back' bimedial rectus recession. STUDY TYPE: Retrospective case series analysis. METHODS: Patients managed by a single surgeon over a 4-year study period were categorized into esotropia types: infantile, partially accommodative, nonaccommodative and secondary esotropia. Postoperative alignment was compared between types, and regression modelling used to examine factors predicting surgical response. RESULTS: In all, 95% (18/19) of children with partially accommodative esotropia achieved postoperative deviation <15 prism dioptres from orthotropia, compared to 56% (15/27) of children with infantile esotropia, 69% (11/16) of children with non-accommodative esotropia and all (2/2) of those with secondary esotropia. Surgical response (Delta/mm recession performed) increased with the magnitude of both preoperative deviation (P<0.001) and anisometropia (P<0.001); the effect of deviation on surgical response was reduced by amblyopia (P=0.02). Age at surgery was statistically associated (P=0.002) but had negligible clinical effect on response. CONCLUSIONS: Surgical response to hang-back recession may be partially predicted by preoperative factors.     

Risk factors for the development of accommodative esotropia following treatment for infantile esotropia.

PURPOSE: One aim of the study was to determine whether accommodative esotropia after surgical alignment in infantile esotropia occurs because a pre-existing accommodative component is unmasked at the time of surgery or whether it occurs as a sequela of infantile esotropia. A second aim of the present study was to examine risk factors for accommodative esotropia after surgery for infantile esotropia. METHODS: A total of 80 consecutive patients who were enrolled in a prospective study of infantile esotropia had been followed for more than 4 years and had achieved orthoposition were included. Twelve potential risk factors were examined: age at onset, initial esodeviation, initial refractive error, age at alignment, delay in alignment, presurgical glasses, amblyopia, additional surgical procedures, unstable alignment, increase in hypermetropia, peripheral fusion, and stereopsis. Mantel-Haenszel odds ratios were computed for each factor and were corrected to relative risks. RESULTS: Overall, 48 of 80 children (60%) developed accommodative esotropia at a mean age of 33 months. Increasing hypermetropia, delay in alignment, and poor stereopsis posed significant risks for accommodative esotropia. The remaining 9 factors were not associated with increased risk for accommodative esotropia. CONCLUSIONS: Accommodative esotropia is unlikely to be a pre-existing condition in most cases because the mean age of onset was 23 months postoperative and the prevalence of preoperative hypermetropia greater than +3.00 D was low. Both delay in alignment and stereopsis risk factors may reflect compromised binocular sensory status that allows accommodative esotropia to occur at low to moderate levels of hypermetropia. Identification of children treated for infantile esotropia who are at risk for accommodative esotropia may allow for prevention or early treatment.     

283例手术治疗共同性内斜视临床特点分析

目的探讨共同性内斜视各类型分布、不同类型及手术年龄对双眼单视功能的影响。方法回顾分析手术治疗的共同性内斜视283例,统计各类型内斜视的分布。重点分析婴儿内斜视、非调节性内斜视和部分调节性内斜视三种类型及其手术年龄对双眼单视功能的影响。结果 283例共同性内斜视患者中,婴儿内斜视136例(48.57%)、非调节性内斜视77例(27.21%)、部分调节性内斜视44例(15.55%)、残余性内斜视18例(6.36%)、知觉性内斜视4例(1.41%)、连续性内斜视4例(1.41%)。部分调节性内斜视存在融合功能和远近立体视的比率均高于婴儿内斜视和非调节性内斜视,P<0.05;而婴儿内斜视和非调节性内斜视远近立体视差别不大,P>0.05;<2岁患儿融合及近立体视存在率高于2～9岁和>9岁患儿,P<0.05。结论在手术治疗的共同性内斜视中,婴儿内斜视占首位。部分调节性内斜视对双眼单视功能影响最小。手术年龄小有助于双眼单视功能的改善。     

Accommodative esotropia following surgical treatment of infantile esotropia: frequency and risk factors

Purpose: We aimed to examine the frequency of and risk factors for the development of accommodative esotropia following surgical treatment for infantile esotropia. Methods: A total of 29 children were recruited. Potential risk factors for the development of accommodative esotropia included: sex; angle of deviation at initial and final visits; cycloplegic refractive error at initial and final visits; increase in hyperopia; amblyopia; amblyopia treatment; age at surgical treatment; pre‐ and postoperative latent nystagmus; dissociated vertical deviation or inferior oblique muscle overaction; additional surgical procedures; unstable alignment, and binocular sensory status. Results: Overall, 14 (48.2%) of 29 children developed accommodative esotropia during the 36‐ to 132‐month postoperative follow‐up period. Twelve (85.7%) of the 14 patients developed refractive accommodative esotropia and two developed non‐refractive accommodative esotropia. The onset of accommodative esotropia occurred at a mean of 8.8 months (range 6–24 months) after the initial surgical alignment. This corresponded to a mean age of onset for accommodative esotropia of 43.2 months. We determined that, among children with infantile esotropia, those who had hyperopia of ≥ 3.0 D and increasing hyperopia after surgery and those who did not develop dissociated vertical deviation during the follow‐up period were more likely to develop accommodative esotropia. Conclusions: Children who have the established risk factors should be followed closely for the development of accommodative esotropia. The treatment of these children with appropriate glasses may prevent the development of adverse effects of accommodative esotropia on sensory and motor functions.     

Assessment of central and peripheral fusion and near and distance stereoacuity in intermittent exotropic patients before and after strabismus surgery.

PURPOSE: To determine whether central fusion and distance stereoacuity are useful as objective measures in assessing the need for and success of surgery for intermittent exotropia (X[T]). METHODS: A prospective, institutional, clinical trial was conducted of 26 consecutive patients with X(T) who were undergoing strabismus surgery in whom fusion (central and peripheral) and stereoacuity (at near and distance) were assessed preoperatively and postoperatively, as well as in 112 normal subjects. To obtain accurate measurements with sensory tests, the lower age was limited to 5 years for inclusion. A successful surgical alignment was defined as an exotropia of 10 prism diopters or less at 6 m. Sensory and motor outcome measures were determined 1 year after surgery. RESULTS: The successful surgical alignment rate was 69%. All patients with X(T) demonstrated peripheral fusion, whereas 35% demonstrated central suppression preoperatively and postoperatively. Central fusion was not predictive of surgical outcome (P = .078); however, there was a trend toward less surgical success in patients with central suppression. Patients with X(T) exhibited good near stereoacuity before and after surgery. Distance stereoacuity in patients with X(T) preoperatively was significantly diminished compared with normal subjects (P < .001) and was improved in 58% postoperatively. Patients who achieved successful surgical alignment had a greater likelihood of demonstrating distance stereoacuity improvement postoperatively than patients who failed to achieve successful surgical alignment (P = .003). Patients with central suppression were unlikely to improve their distance stereoacuity postoperatively (P = .014). CONCLUSIONS: Successful surgery may improve distance stereoacuity. Better distance stereoacuity and central fusion are frequently associated with better surgical success in X(T).     

Successful treatment of anisometropic amblyopia with spectacles alone.

BACKGROUND: The efficacy of treating anisometropic amblyopia with occlusion therapy is well known. However, this form of treatment can be associated with risks. Spectacle correction alone may be a successful and underutilized form of treatment. METHODS: The records of 28 patients treated successfully for anisometropic amblyopia with glasses alone were reviewed. Age, initial visual acuity and stereoacuity, and nature of anisometropia were analyzed to assess associations with time required for resolution, final visual acuity, and stereoacuity. Incidence of amblyopia recurrence and results of subsequent treatment, including patching, were also studied. RESULTS: Mean time to amblyopia resolution (interocular acuity difference 相似文献   

Stereopsis and long-term stability of alignment in esotropia.

PURPOSE: Recent studies of infantile and accommodative esotropia (ET) have focused on stereoacuity as a final outcome measurement for judging the success or failure of treatment. The purpose of the present study was to extend this approach by evaluating whether the presence of stereopsis developing immediately after surgical alignment or optical correction plays a role in maintenance of long-term alignment. METHODS: Random-dot stereoacuity was assessed within 3 months of initial surgical alignment in 70 children with infantile ET and within 3 months of initial optical correction in 66 children with accommodative ET. At > or = 5 years of age, adverse outcomes were assessed including loss of alignment, amblyopia, and nil stereopsis. Risk-factor analysis was used to evaluate whether early nil stereopsis increased the risk for subsequent adverse outcomes. RESULTS: In the infantile ET cohort, early nil stereopsis was associated with a 3.6 times (95% confidence interval [CI] 2.4 to 4.1) greater risk of surgery for recurrent ET or consecutive exotropia and a 4.2 times (95% CI 3.3 to 4.4) greater risk for nil stereopsis at > or = 5 years of age. In the accommodative ET cohort, early nil stereopsis was associated with a 17.4 times (95% CI 3.3 to 32.2) greater risk of surgery for ET and a 32.2 times (95% CI 15.8 to 35.6) greater risk for nil stereopsis at > or = 5 years of age. CONCLUSION: Treatment protocols designed to optimize stereoacuity outcomes promote long-term stability of alignment.     

屈光参差性弱视儿童治愈后的双眼视觉研究

【摘要】 目的 了解屈光参差性弱视儿童治愈后双眼视觉状况。设计 回顾性病例系列。研究对象 屈光参差性弱视儿童74例,正常儿童74例。方法 采用同视机和颜少明《立体视觉检查图》对74例 经治疗矫正视力已≥0.9的屈光参差性弱视儿童和74例正常儿童的双眼视觉功能进行检测。主要指 标  同时知觉、远融合范围、定性远立体视、 立体视锐度。结果 （1）屈光参差性弱视儿童基本 治愈后其远立体视低于正常儿童（χ2 =11.331,P=0.001）;同时视（χ2 =1.855,P=0.173）及 远融合范围（χ2 =1.012,P=0.603）无明显差异。（2）屈光参差性弱视儿童基本治愈后其近立体 视锐度明显低于正常儿童（χ2 =27.759,P=0.000）。（3）屈光参差性弱视程度越轻,近立体视 锐度的改善越显著（χ2 =17.116,P=0.009）;而同时视（χ2 =0.879,P=0.644）、远融合范围 （χ2 =7.930,P=0.094）、远立体视（χ2 =2.854,P=0.240）的改善无明显差异。结论 屈光参 差性弱视严重影响立体视觉的发育。即使治疗后视力达到正常,其立体视仍低于正常儿童。屈光参 差程度越重,对近立体视锐度的影响越显著。（眼科,2012, 21: 395-397）     

Factors influencing stereoacuity in accommodative esotropia.

PURPOSE: Despite successful optical realignment, many children with accommodative esotropia (ET) have abnormal stereoacuity. In a prospective study, we examined the influence of age of onset, age at alignment, duration of constant misalignment, and accommodative convergence/accommodation ratio on random dot stereoacuity outcomes in accommodative ET. METHODS: Participants were 111 consecutive children with accommodative ET. Random dot stereoacuity was measured using the Randot preschool stereoacuity test, the Randot stereoacuity test, the infant random dot stereoacuity cards, and the Lang 1. RESULTS: Age of onset has only a minor influence on stereoacuity (P <.02); children with onset >/=age 25 months have better stereoacuity compared with children with an onset between ages 7 and 17 months. Age at alignment has a minor influence on stereoacuity (P <.001); children with intermittent ET who have been treated have better stereoacuity than children with a constant ET aligned between ages 6 and 24 months and after age 24 months. Duration of constant misalignment has the strongest influence on stereoacuity (P <.001); children who had intermittent misalignment or who had a constant misalignment of less than 4 months' duration have better stereoacuity than patients who had a constant misalignment greater than 4 months' duration. The accommodative convergence/accommodation ratio does not influence stereoacuity outcomes (P >.10). CONCLUSIONS: Fine random dot stereoacuity is associated with a constant misalignment of less than 4 months' duration. These findings promote prompt and aggressive treatment of accommodative ET at the onset of intermittent or constant misalignment.     

Strabismus management

In this article, three topics of current interest in strabismus are covered. These include strabismus after glaucoma implant surgery, management of accommodative esotropia, and the timing of treatment for strabismic amblyopia. Glaucoma implants have improved our results with difficult glaucoma syndromes, however, a high incidence of postoperative strabismus has been associated with this procedure. The mechanism of the strabismus has not been clearly defined in previous literature, but in this article we describe three mechanisms that cause strabismus after glaucoma implant surgery and describe methods for managing this problem. The standard management of accommodative esotropia has historically resulted in a large number of undercorrections. Patients with accommodative esotropia have good fusion potential as the strabismus is acquired and binocular visual development occurred during the critical period. Recent studies indicate that we should increase our surgical numbers when managing patients with accommodative esotropia. Various treatment strategies are covered in the section on accommodative esotropia. Finally, a discussion on the management of strabismic amblyopia is presented. The importance of treating amblyopia first, then secondarily correcting the strabismus is emphasized.